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Nolen A, Selby D, Qureshi F, Mills A. Practices of and Perspectives on Palliative Sedation Among Palliative Care Physicians in Ontario, Canada: A Mixed-Methods Study. Palliat Med Rep 2024; 5:94-103. [PMID: 38415075 PMCID: PMC10898238 DOI: 10.1089/pmr.2023.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/29/2024] Open
Abstract
Background Palliative sedation (PS) is a therapeutic intervention employed to manage severe and refractory symptoms in terminally ill patients at end of life. Inconsistencies in PS practice guidelines coupled with clinician ambiguity have resulted in confusion about how PS is best integrated into practice. Understanding the perspectives, experiences, and practices relating to this modality will provide insight into its clinical application and challenges within the palliative care landscape. Objective The aim is to explore the perspectives of palliative care physicians administering PS, including how practitioners define PS, factors influencing decision making about the use of PS, and possible reasons for changes in practice patterns over time. Methods A survey (n = 37) and semistructured interviews (n = 23) were conducted with palliative care physicians throughout Ontario. Codes were determined collaboratively and applied line-by-line by two independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated through reflexive thematic analysis. Results Five key themes were identified: (1) lack of standardization, (2) differing definitions, (3) logistical challenges, (4) perceived "back-up" to Medical Assistance in Dying, and (5) tool of the most responsible physician. Conclusion There was significant variability in how participants defined PS and in frequency of use of PS. Physicians described greater ease implementing PS when practicing in palliative care units, with significant barriers faced by individuals providing home-based palliative care or working as consultants on inpatient units. Educational efforts are required about the intent and practice of PS, particularly among inpatient interprofessional teams.
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Affiliation(s)
- Amy Nolen
- Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
- Division of Palliative Care and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Debbie Selby
- Division of Palliative Care and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fahad Qureshi
- Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anneliese Mills
- Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Maeda S, Morita T, Yokomichi N, Imai K, Tsuneto S, Maeda I, Miura T, Ishiki H, Otani H, Hatano Y, Mori M. Continuous Deep Sedation for Psycho-Existential Suffering: A Multicenter Nationwide Study. J Palliat Med 2023; 26:1501-1509. [PMID: 37289183 DOI: 10.1089/jpm.2023.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Background: There is ongoing debate on whether continuous deep sedation (CDS) for psycho-existential suffering is appropriate. Objective: We aimed to (1) clarify clinical practice of CDS for psycho-existential suffering and (2) assess its impact on patients' survival. Methods: Advanced cancer patients admitted to 23 palliative care units in 2017 were consecutively enrolled. We compared patients' characteristics, CDS practices, and survival between those receiving CDS for psycho-existential suffering ± physical symptoms and only for physical symptoms. Results: Of 164 patients analyzed, 14 (8.5%) received CDS for psycho-existential suffering ± physical symptoms and only one of them (0.6%) solely for psycho-existential suffering. Patients receiving CDS for psycho-existential suffering, compared with those only for physical symptoms, were likely to have no specific religion (p = 0.025), and desired (78.6% vs. 22.0%, respectively; p < 0.001) and requested a hastened death more frequently (57.1% vs. 10.0%, respectively; p < 0.001). All of them had a poor physical condition with limited estimated survival, and mostly (71%) received intermittent sedation before CDS. CDS for psycho-existential suffering caused greater physicians' discomfort (p = 0.037), and lasted for longer (p = 0.029). Dependency, loss of autonomy, and hopelessness were common reasons for psycho-existential suffering that required CDS. The survival time after CDS initiation was longer in patients receiving it for psycho-existential suffering (log-rank, p = 0.021). Conclusion: CDS was applied to patients who suffered from psycho-existential suffering, which often associated with desire or request for a hastened death. Further studies and debate are warranted to develop feasible treatment strategies for psycho-existential suffering.
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Affiliation(s)
- Sayaka Maeda
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
- Research Association for Community Health, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Osaka, Japan
| | - Tomofumi Miura
- Department of Palliative Medicine, National Cancer Center Hospital East, Chiba, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Otani
- Department of Palliative and Supportive Care, St. Mary's Hospital, Fukuoka, Japan
- Department of Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yutaka Hatano
- Department of Palliative Care, Daini Kyoritsu Hospital, Kawanishi, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Yang CH, Chen PJ, Mori M, Morita T, Cheng SY, Suh SY, Kim SH, Yokomichi N, Imai K, Ito S, Yamaguchi T, Hiratsuka Y, Tsuneto S, Maeda S. Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study. Jpn J Clin Oncol 2023:7145896. [PMID: 37114920 DOI: 10.1093/jjco/hyad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan. METHODS Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries. RESULTS A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001). CONCLUSIONS Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.
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Affiliation(s)
- Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University, International St. Mary's Hospital, Incheon, South Korea
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoko Ito
- Hospice, The Japan Baptist Hospital, Kyoto, Japan
| | - Takashi Yamaguchi
- Division of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sayaka Maeda
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
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Hwang IC. Current Status and Future Directions of Research on Palliative Sedation. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:193-197. [PMID: 37674671 PMCID: PMC10179994 DOI: 10.14475/jhpc.2022.25.4.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 09/08/2023]
Abstract
Patients with terminal cancer experience very severe symptoms during the end of life, and palliative sedation (PS) may be considered if those symptoms are refractory to any other treatment. This brief report presents ethical considerations, practices, and recent concerns on PS. PS is quite different from euthanasia. There is a lack of consensus and standards on protocols, but its notable effects have been reported in hospice care settings. Most studies to date have reported no difference in survival between patients receiving PS and those not, and PS must be conducted proportionally with the lightest level of sedation. The most common indication for PS is delirium, and midazolam is the main sedative used. It is recommended that information regarding PS should be provided to patients and their caregivers repeatedly as early as possible. Existential suffering alone is not an indication for PS, and there is a lack of evidence on bispectral analysis. Additional research on PS is needed in Korea.
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Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Grüne B, Meesters S, Bausewein C, Schildmann E. Challenges and Strategies Regarding Sedation at the End of Life in Hospitals and Nursing Homes. J Pain Symptom Manage 2022; 63:530-538. [PMID: 34921935 DOI: 10.1016/j.jpainsymman.2021.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/26/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Sedation is an accepted, but controversially discussed and challenging measure to treat suffering at the end of life. Although most people die in hospitals or nursing homes, little is known how professionals in these settings deal with sedatives and sedation at the end of life. OBJECTIVES To explore 1) challenges regarding use of sedatives and sedation at the end of life in hospitals and nursing homes, and 2) strategies, and supportive measures to meet these challenges, as perceived by nurses and physicians. METHODS Multicenter qualitative interview study. Forty-nine participants: 12 general practitioners and 12 nurses from five nursing homes, 12 physicians, and 13 nurses from five hospital departments (hematology/oncology (n = 2), neurology, geriatrics, gynecology). Semi-structured qualitative interviews. Data analysis guided by framework approach. RESULTS Perceived challenges relate to three levels of the care situation: individual, interaction with others, and work environment. The main challenge was defining the adequate timing and/or dose. Other challenges, e.g., disagreements regarding indication or legal uncertainties, were highly interrelated, and strongly associated with this major challenge. Reported strategies and supportive measures to address challenges also corresponded to the three interrelated levels. Major named strategies were education and training, joint decision-making within the team and regular discussion with the patient and family. On the level work environment, no implemented strategies, but wishes for change were identified. CONCLUSION To meet the identified challenges in a sustainable way and enable continuous improvement of quality of care, best practice recommendations, and other supportive measures have to address all identified levels of challenges.
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Affiliation(s)
- Bettina Grüne
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany; German Youth Institute (DJI), Department of Youth and Youth Services (B.G.), Munich, Germany.
| | - Sophie Meesters
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine (B.G., S.M., C.B., E.S.), University Hospital, LMU Munich, Germany
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Vissers S, Robijn L, Dierickx S, Mortier F, Cohen J, Deliens L, Chambaere K. Control Measures for Continuous Deep Sedation Until Death: A Framing Analysis of the Views of Physicians. QUALITATIVE HEALTH RESEARCH 2021; 31:2390-2402. [PMID: 34617830 DOI: 10.1177/10497323211037648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Physicians have been subject to increasing external control to improve their medical practice, and scholars have theorized extensively about their opposition to such control. However, little empirical attention has been paid to the views and reasoning that lie behind this opposition. An in-depth understanding is necessary for enhancing the effectiveness and efficiency of external controls, and continuous deep sedation until death (CDS) is an interesting case in this regard. This study aims to explore how physicians frame control measures for CDS. We conducted 47 semi-structured interviews with Belgian physicians in 2019. A qualitative framing analysis was performed to analyze their views and reasoning. This study reveals that physicians approach CDS practice and control measures with different emphases. Controlling by mechanisms of professional self-regulation and state governance are put forward as appropriate means to improve CDS practice. Policymakers should take into consideration physicians' frames to develop sound control measures.
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Affiliation(s)
- Stijn Vissers
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sigrid Dierickx
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Freddy Mortier
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Naito AS, Morita T, Imai K, Ikenaga M, Hamano J, Abo H, Kizawa Y, Tsuneto S. Development of a Scoring System to Determine Proportional Appropriateness of Continuous Deep Sedation: A Concept-of-Proof Study. J Palliat Med 2021; 24:1539-1544. [PMID: 34297628 DOI: 10.1089/jpm.2020.0773] [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: 11/12/2022] Open
Abstract
Context: Some patients require continuous deep sedation (CDS) for refractory symptoms despite intensive palliative care. The principle of proportionality is proposed on the basis of clinical decisions, but no validated tools to assist such decision making are available. Aim: To develop a scoring system to determine whether CDS is proportionally appropriate. Subjects and Methods: A secondary analysis of a nationwide questionnaire survey of Japanese palliative care specialists was performed. Physicians were asked to rate the degree that they believed CDS to be appropriate in a total of 27 scenarios based on a combination of 3 factors with 3 levels: (1) the estimated survival (days, weeks, and months), (2) the patient's wish (clear and consistent, somewhat unclear and/or inconsistent, and unclear or inconsistent), and (3) confidence in refractoriness of the symptom (definite, probable, and unsure). Based on logistic regression analyses, a scoring system with two formulas (the proportionality score to determine that continuous deep sedation is appropriate [ProScoreCDS-appropriate] and proportionality score to determine that continuous deep sedation is inappropriate [ProScoreCDS-inappropriate]) to predict specialists' decision that CDS is appropriate or inappropriate was developed. The accuracy of the formulas was investigated. Results: Among 695 palliative care specialists, 469 returned the questionnaire (response rate, 69%) and 440 were analyzed. Logistic regression analyses identified that all three factors were significantly associated with physicians' decisions about the appropriateness of performing CDS. Using weighted value, the total score ranged from 3 to 67 for ProScoreCDS-appropriate, and 3 to 27 for ProScoreCDS-inappropriate. The area under the curve (AUC) values of ProScoreCDS-appropriate and ProScoreCDS-inappropriate were 0.88 (95% confidence interval [CI], 0.87-0.89) and 0.81 (95% CI, 0.81-0.82), respectively. Using cutoff points of 41 and 14, sensitivity and specificity were 68.6% and 88.9% for ProScoreCDS-appropriate and 67.7% and 76.0% for ProScoreCDS-inappropriate, respectively. Conclusion: A scoring system to determine whether CDS is proportionally appropriate can be constructed, and a further study to develop a clinical tool is promising.
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Affiliation(s)
- Akemi Shirado Naito
- Department of Palliative Care, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Tatsuya Morita
- Palliative Care Team, Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Masayuki Ikenaga
- Hospice Children's Hospice Hospital, Yodogawa Christian Hospital, Osaka, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hirofumi Abo
- Department of Palliative Medicine, Rokko Hospital, Kobe, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Association between continuous deep sedation and survival time in terminally ill cancer patients. Support Care Cancer 2020; 29:525-531. [PMID: 32415383 DOI: 10.1007/s00520-020-05516-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Our study aimed to evaluate the association between CDS and survival time using the likelihood of receiving CDS to select a matched non-CDS group through an accurate measurement of survival time based on initiation of CDS. METHODS A retrospective cohort study was performed using an electronic database to collect data regarding terminally ill cancer patients admitted to a specialized palliative care unit from January 2012 to December 2016. We first used a Cox proportional hazard model with receiving CDS as the outcome to identify individuals with the highest plausibility of receiving CDS among the non-CDS group (n = 663). We then performed a multiple regression analysis comparing the CDS group (n = 311) and weighted non-CDS group (n = 311), using initiation of CDS (actual for the CDS group; estimated for the non-CDS group) as the starting time-point for measuring survival time. RESULTS Approximately 32% of participants received CDS. The most common indications were delirium or agitation (58.2%), intractable pain (28.9%), and dyspnea (10.6%). Final multiple regression analysis revealed that survival time was longer in the CDS group than in the non-CDS group (Exp(β), 1.41; P < 0.001). Longer survival with CDS was more prominent in females, patients with renal dysfunction, and individuals with low C-reactive protein (CRP) or ferritin, compared with their counterpart subgroup. CONCLUSIONS CDS was not associated with shortened survival; instead, it was associated with longer survival in our terminally ill cancer patients. Further studies in other populations are required to confirm or refute these findings.
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