[Austrian guideline for palliative sedation therapy (long version) : Results of a Delphi process of the Austrian Palliative Society (OPG)]

[Comfort Terminal Care in the intensive care unit: recommendations for practice]

BACKGROUND AND OBJECTIVE

The Working Group on Ethics in Anesthesia and Intensive Care Medicine of the Austrian Society for Anesthesiology Resuscitation and Intensive Care Medicine (ÖGARI) already developed documentation tools for the adaption of therapeutic goals 10 years ago. Since then the practical implementation of Comfort Terminal Care in the daily routine in particular has raised numerous questions, which are discussed in this follow-up paper and answered in an evidence-based manner whenever possible.

RESULTS

The practical implementation of pain therapy and reduction of anxiety, stress and respiratory distress that are indicated in the context of Comfort Terminal Care are described in more detail. The measures that are not (or no longer) indicated, such as oxygen administration and ventilation as well as the administration of fluids and nutrition, are also commented on. Furthermore, recommendations are given regarding monitoring, (laboratory) findings and drug treatment and the importance of nursing actions in the context of Comfort Terminal Care is mentioned. Finally, the support for the next of kin and the procedure in the time after death are presented.

DISCUSSION

A change in treatment goals with a timely switch to Comfort Terminal Care enables good and humane care for seriously ill patients and their relatives at the end of life and the appreciation of their previous life with the possibility of positive experiences until the end.

Palliative sedation: ethics in clinical practice guidelines - systematic review

OBJECTIVES

The objective of our study was to determine whether, and to what degree, the ethical dimension was present in clinical practice guidelines (CPGs) on palliative sedation, and to identify the ethical issues with respect to the different forms of this practice. The purpose was purely to be descriptive; our aim was not to make any kind of normative judgements on these ethical issues or to develop our own ethical recommendations.

METHODS

We performed a systematic review of CPGs on the palliative sedation of adults, focusing our analysis on the ethical dimension of these texts and the ethical issues of this practice. The study protocol is registered on PROSPERO.

RESULTS

In total, 36 current CPGs from four continents (and 14 countries) were included in our analysis. Generally, ethics was rarely referred to or absent from the CPGs. Only six texts contained a specific section explicitly related to ethics. Ethical issues were named, conceptualised and presented in heterogeneous, often confusing ways. It was impossible to identify the ethical issues of each form of palliative sedation. Ethics expertise was not involved in the development of most of the CPGs and, if it was, this did not always correlate with the ethical dimension of the document.

CONCLUSIONS

Effective cooperation between palliative care clinicians and ethicists should be encouraged, in order to integrate in particular the crucial ethical issues of continuous deep sedation until death when developing or updating CPGs on palliative sedation.

Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates

Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.

Sedation in Palliative Care—a Clinically Oriented Overview of Guidelines and Treatment Recommendations

BACKGROUND

The appropriate provision of sedation as a last resort for the relief of suffering in palliative care is dealt with variably in actual practice. This article is intended as an overview of practically relevant information found in treatment recommendations and guidelines.

METHODS

A systematic literature search was conducted in the PubMed, Scopus, and Google Scholar databases, and a manual search was carried out online. Recommendations that were not available in either German or English, or that were specific to pediatric practice, were excluded. Publication quality was assessed with the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II). The recommendations in the documents were qualitatively evaluated.

RESULTS

29 publications (11 journal articles, 18 other) of varying quality according to AGREE II were included. All recommendations and guidelines were essentially based on expert consensus. The common indications for sedation are otherwise intractable delirium, dyspnea, and pain, in patients with a life expectancy of no more than two weeks. Existential distress is a controversial indication. The drug of first choice is midazolam. As the sedating effect of opioids is hard to predict, they should not be used as sedatives. The risks of sedation include respiratory and circulatory depression, as well as the loss of communicative ability, control, and autonomy. It is generally recommended that the patient's symptom burden and depth of sedation should be monitored; clinical and technically supported monitoring are recommended in some publications as well, depending on the situation.

CONCLUSION

There is a broad consensus in favor of sedation to relieve suffering in the last days and hours of life. Recommendations vary for patients with a longer life expectancy and for those with existential distress, and with respect to monitoring.

Clinical Practice Guidelines on Palliative Sedation Around the World: A Systematic Review

Objective: The principal aim of this study was to identify, systematically and transparently, clinical practice guidelines (CPGs) on palliative sedation from around the world. Methods: A systematic search was performed using 5 databases, grey literature search tools, citation tracking, and contact with palliative care experts across the world. Current CPGs accredited by an international, national, or regional authority, published in English, German, French, or Italian, were subjected to content analysis. Results: In total, 35 CPGs from 14 countries and 1 international CPG were included in the analysis. The CPGs had diverse formal characteristics. Their thematic scope was difficult to analyze and compare because of differences in the terms and definitions of palliative sedation in those texts. We identified 3 main situations: (1) CPGs with a fully explicit thematic scope; (2) CPGs with a partially explicit thematic scope; and (3) CPGs without an explicit thematic scope. Several CPGs explicitly stated what forms of sedation were excluded from the text. However, this presentation was often confusing. Conclusion: Our review provides several pieces of information that could guide international reflections in this field, and be used to develop or update CPGs at all levels. Efforts should be made to clarify the thematic scope of each CPG on palliative sedation, in order to generate an understanding of the forms of this therapy addressed in the text.

Off-label use in adult palliative care - more common than expected. A retrospective chart review

OBJECTIVE

Off-label drug use seems to be integral to adult palliative care pharmacotherapy. Balancing potential risks and benefits in the context of limited therapeutic options is challenging. To provide specific support for clinicians in dealing with off-label use, it is essential to understand off-label use in everyday clinical practice. The aim of this pilot study was to quantify and describe off-label use in an adult palliative care unit.

METHODS

Retrospective chart review of all adult patients treated on a palliative care unit in October 2017. All data on drug use (eg, indication, dose, route of administration) were extracted and matched with the prescribing information. Identified off-label use was subsequently compared with recommendations in the relevant literature. The main outcome measure was frequency and type of off-label drug use.

RESULTS

Some 2352 drug application days and 93 drugs were identified for 28 patients. Of all drugs, 47 (51%) were used off-label at least once. Most off-label uses concerned indication (57%) followed by mode of administration. In drugs highly relevant to palliative care the rate of off-label use was as high as 67%. The extent to which off-label therapy was supported by literature was very variable and ranged from 0% to 88%.

CONCLUSIONS

These data from a single unit confirm the high prevalence of off-label use in palliative medicine and demonstrate that off-label use in adult palliative care is multifaceted. The data presented allow for a more precise characterisation of various aspects of off-label use in order to derive concrete further measures for research and clinical practice.

A case report of posttraumatic stress disorder at the end of life

A case of posttraumatic stress disorder (PTSD) in the last days of life is presented. It shows insufficient pharmacological therapy and PTSD that was not recognized early enough. We discuss the dilemma caused by the necessity of a long-term psychotherapy and the challenge of little time being left at the end of life. Additionally, a language barrier can be a main reason for misinterpreting symptoms of PTSD.

What do you mean by "palliative sedation"? : Pre-explicative analyses as preliminary steps towards better definitions

BACKGROUND

Sedation in palliative care is frequently but controversially discussed. Heterogeneous definitions and conceptual confusion have been cited as contributing to different problems 1) relevant to empirical research, for example, inconsistent data about practice, the 'data problem', and 2) relevant for an ethically legitimate characterisation of the practice, the 'problem of ethical pre-emption'. However, little is known about how exactly definitions differ, how they cause confusion and how this can be overcome.

METHOD

Pre-explicative analyses: (A) systematic literature search for guidelines on sedation in palliative care and systematic decomposition of the definitions of the practice in these guidelines; (B) logical distinction of different ways through which the two problems reported might be caused by definitions; and (C) analysis of how content of the definitions contributes to the problems reported in these different ways.

RESULTS

29 guidelines from 14 countries were identified. Definitions differ significantly in both structure and content. We identified three ways in which definitions can cause the 'data problem' - 1) different definitions, 2) deviating implicit concepts, 3) disagreement about facts. We identified two ways to cause the problem of ethical pre-emption: 1) explicit or 2) implicit normativity. Decomposition of definitions linked to the distinguished ways of causing the conceptual problems shows how exactly single parts of definitions can cause the problems identified.

CONCLUSION

Current challenges concerning empirical research on sedation in palliative care can be remediated partly by improved definitions in the future, if content and structure of the used definitions is chosen systematically. In addition, future research should bear in mind that there are distinct purposes of definitions. Regarding the 'data problem', improving definitions is possible in terms of supplementary information, checking for implicit understanding, systematic choice of definitional elements. 'Ethical pre-emption', in contrast, is a pseudo problem if definitions and the relationship of definitions and norms of good practice are understood correctly.

[Voluntary stopping eating and drinking (VSED) : A position paper of the Austrian Palliative Society]

In some cases terminally ill patients fear of prolonged dying and suffering can manifest itself in the voluntary refusal of food and fluids, aiming to accelerate the dying process. This represents a considerable area of conflict, because of the ethical responsibility to not aid a person's death but also to respect a patients autonomy.There is a clear separation between an assisted suicide and following a patient's wishes. Not to accept the voluntary refusal of FVNF would have to be considered as forced treatment of patients while they are capable of self-determination.Several symptoms associated with or caused by voluntary refusal of food and fluids do require palliative care. It is important to be aware, that caring for dying patients refusing food and fluids and accepting their choice is not synonymous with assisted suicide. Rather is it part of medical and nursing care for patients during their dying-process.An interprofessional working group of the Austrian Palliative Society (OPG) intends to shed light on the legal, ethical, medical and nursing related aspects concerning this subject of growing public and professional interest.