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Heino L, Stolt M, Haavisto E. The practices and attitudes of nurses regarding palliative sedation: A scoping review. Int J Nurs Stud 2020; 117:103859. [PMID: 33545642 DOI: 10.1016/j.ijnurstu.2020.103859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 12/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Palliative sedation is used as a last-resort option to treat refractory symptoms of dying patients. Nurses are important participants in the process of sedation. However, little is known about palliative sedation from a nursing perspective. OBJECTIVES To analyze the practices and attitudes of nurses concerning palliative sedation. DATA SOURCES AND REVIEW METHODS A scoping review guided by Arksey and O`Malley`s methodological framework was used to analyze existing peer-reviewed empirical research on the topic of the practices and attitudes of nurses related to the palliative sedation of patients aged 18 years and older. Of the 316 publications identified from the PubMed, CINAHL and Cochrane Library, 17 full-text articles were included in this review. The data of the included articles were charted (author(s), year of publication, country, objectives, study design, data collection, setting, respondents, definition of palliative sedation, focus of the study and key findings), and the results were summarized with inductive content analysis. The PRISMA-ScR checklist was used as a guideline for the reporting in this review. RESULTS During the decision-making concerning the start of palliative sedation, nurses usually have an advocatory and supportive role, although the role varies between different countries. This role then changes to a relatively independent performance of sedation; including administration of the medication, monitoring the effectiveness of sedation, and in some cases taking decisions concerning the medication and dosage policy. Further, nurses provide information and compassionate care to both the patient and the family during the process of palliative sedation. Most nurses view palliative sedation as a positive and sometimes necessary last resort therapy to relieve refractory suffering of dying patients. However, sedation poses ethical problems for many nurses. These problems especially concern the essential elements of deciding to use palliative sedation, the depth of sedation, the potential for shortening life, and the loss of social interaction. CONCLUSIONS Nurses play a key role in palliative sedation, as they often perform sedation independently and have important information about the needs and wishes of both patients and their families due to their unique position at the bedside of the patient. Although nurses generally see palliative sedation as a positive practice for selected patients, many of them feel it is ethically controversial. This scoping review reveals a great need for further research and discussion on the practices and attitudes of nurses regarding palliative sedation.
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Affiliation(s)
- Linda Heino
- Bachelor of Health Sciences, Department of Nursing Science, University of Turku, Turku, Finland.
| | - Minna Stolt
- Department of Nursing Science, University of Turku, Turku and Turku University Hospital, Turku, Finland
| | - Elina Haavisto
- Department of Nursing Science, University of Turku, Turku and Satakunta Central Hospital, Pori, Finland
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2
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Wright DK, Gastmans C, Vandyk A, de Casterlé BD. Moral identity and palliative sedation: A systematic review of normative nursing literature. Nurs Ethics 2019; 27:868-886. [DOI: 10.1177/0969733019876312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.
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Fritz L, Dirven L, Reijneveld JC, Koekkoek JAF, Stiggelbout AM, Pasman HRW, Taphoorn MJB. Advance Care Planning in Glioblastoma Patients. Cancers (Basel) 2016; 8:E102. [PMID: 27834803 PMCID: PMC5126762 DOI: 10.3390/cancers8110102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/20/2016] [Accepted: 11/02/2016] [Indexed: 12/27/2022] Open
Abstract
Despite multimodal treatment with surgery, radiotherapy and chemotherapy, glioblastoma is an incurable disease with a poor prognosis. During the disease course, glioblastoma patients may experience progressive neurological deficits, symptoms of increased intracranial pressure such as drowsiness and headache, incontinence, seizures and progressive cognitive dysfunction. These patients not only have cancer, but also a progressive brain disease. This may seriously interfere with their ability to make their own decisions regarding treatment. It is therefore warranted to involve glioblastoma patients early in the disease trajectory in treatment decision-making on their future care, including the end of life (EOL) care, which can be achieved with Advance Care Planning (ACP). Although ACP, by definition, aims at timely involvement of patients and proxies in decision-making on future care, the optimal moment to initiate ACP discussions in the disease trajectory of glioblastoma patients remains controversial. Moreover, the disease-specific content of these ACP discussions needs to be established. In this article, we will first describe the history of patient participation in treatment decision-making, including the shift towards ACP. Secondly, we will describe the possible role of ACP for glioblastoma patients, with the specific aim of treatment of disease-specific symptoms such as somnolence and dysphagia, epileptic seizures, headache, and personality changes, agitation and delirium in the EOL phase, and the importance of timing of ACP discussions in this patient population.
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Affiliation(s)
- Lara Fritz
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Jaap C Reijneveld
- Department of Neurology, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
- Department of Neurology, Academic Medical Center, P.O. BOX 22660, 1100 DD Amsterdam, The Netherlands.
| | - Johan A F Koekkoek
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - Anne M Stiggelbout
- Department of Medical Decision Making/Quality of Care, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam, The Netherlands.
| | - Martin J B Taphoorn
- Department of Neurology, Haaglanden Medical Center, P.O. BOX 432, 2501 CK The Hague, The Netherlands.
- Department of Neurology, Leiden University Medical Center, P.O. BOX 9600, 2300 RC Leiden, The Netherlands.
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Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer. Palliat Support Care 2016; 15:148-157. [PMID: 27323872 DOI: 10.1017/s1478951516000419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Palliative sedation is a method of symptom management frequently used in hospices to treat uncontrolled symptoms at the end of life. There is a substantial body of literature on this subject; however, there has been little research into the experiences of hospice nurses when administering palliative sedation in an attempt to manage the terminal restlessness experienced by cancer patients. METHOD Semistructured interviews were conducted with a purposive sample of seven hospice nurses who had cared for at least one patient who had undergone palliative sedation within the past year in a hospice in the south of England in the United Kingdom. A phenomenological approach and Colaizzi's stages of analysis were employed to develop themes from the data. RESULTS Facilitating a "peaceful death" was the primary goal of the nurses, where through the administration of palliative sedation they sought to enable and support patients to be "comfortable," "relaxed," and "calm" at the terminal stage of their illness. Ethical dilemmas related to decision making were a factor in achieving this. These were: medication decisions, "juggling the drugs," "causing the death," sedating young people, the family "requesting" sedation, and believing that hospice is a place where death is hastened. SIGNIFICANCE OF RESULTS Hospice nurses in the U.K. frequently encounter ethical and emotional dilemmas when administering palliative sedation. Making such decisions about using palliative sedation causes general discomfort for them. Undertaking this aspect of care requires confidence and competence on the part of nurses, and working within a supportive hospice team is of fundamental importance in supporting this practice.
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5
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Dirven L, Sizoo EM, Taphoorn MJB. Anaplastic gliomas: end-of-life care recommendations. CNS Oncol 2015; 4:357-65. [PMID: 26509292 DOI: 10.2217/cns.15.31] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite multimodal antitumor treatment, all patients with an anaplastic glioma will be confronted with incurability in due course and enter the end-of-life (EOL) phase; the period when the patients' condition declines and tumor-directed treatment is no longer effective. Although palliative care is important in all stages of the disease, it is of utmost importance in the EOL phase. The main goal of palliative care is to improve or maintain the quality of life of the patients and their relatives through the prevention and relief of suffering. This review focuses on different aspects of the EOL phase (symptoms and signs, EOL decision-making, advance care planning, organization of care and caregiver burden) and will provide recommendations to optimize palliative care.
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Affiliation(s)
- Linda Dirven
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Eefje M Sizoo
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands
| | - Martin J B Taphoorn
- VU University Medical Center, Department of Neurology, POBOX 7057, 1007 MB Amsterdam, The Netherlands.,Medical Center Haaglanden, Department of Neurology, The Hague, The Netherlands
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Henoch I, Carlander I, Holm M, James I, Kenne Sarenmalm E, Lundh Hagelin C, Lind S, Sandgren A, Öhlén J. Palliative Care Research - A Systematic Review of foci, designs and methods of research conducted in Sweden between 2007 and 2012. Scand J Caring Sci 2015; 30:5-25. [DOI: 10.1111/scs.12253] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/06/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Ingela Henoch
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
| | - Ida Carlander
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Maja Holm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Inger James
- School of Health and Medical Sciences; Örebro University; Örebro Sweden
| | - Elisabeth Kenne Sarenmalm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Research and Development Centre; Skaraborg Hospital; Skövde Sweden
| | - Carina Lundh Hagelin
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Sophiahemmet University; Stockholm Sweden
- Research and Development Unit in Palliative care; Stockholms Sjukhem Foundation; Stockholm Sweden
| | - Susanne Lind
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Anna Sandgren
- School of Health Sciences; Jönköping University; Jönköping Sweden
- Center for Collaborative Palliative Care; Department of Health and Caring Sciences; Linneaus University; Kalmar/Växjö Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
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Abarshi E, Rietjens J, Caraceni A, Payne S, Deliens L, Van Den Block L. Towards a standardised approach for evaluating guidelines and guidance documents on palliative sedation: study protocol. BMC Palliat Care 2014; 13:34. [PMID: 25028571 PMCID: PMC4099031 DOI: 10.1186/1472-684x-13-34] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 06/26/2014] [Indexed: 11/20/2022] Open
Abstract
Background Sedation in palliative care has received growing attention in recent years; and so have guidelines, position statements, and related literature that provide recommendations for its practice. Yet little is known collectively about the content, scope and methodological quality of these materials. According to research, there are large variations in palliative sedation practice, depending on the definition and methodology used. However, a standardised approach to comparing and contrasting related documents, across countries, associations and governmental bodies is lacking. This paper reports on a protocol designed to enable thorough and systematic comparison of guidelines and guidance documents on palliative sedation. Methods and design A multidisciplinary and international group of palliative care researchers, identified themes and clinical issues on palliative sedation based on expert consultations and evidence drawn from the EAPC (European Association of Palliative Care) framework for palliative sedation and AGREE II (Appraisal Guideline Research and Evaluation) instrument for guideline assessment. The most relevant themes were selected and built into a comprehensive checklist. This was tested on people working closely with practitioners and patients, for user-friendliness and comprehensibility, and modified where necessary. Next, a systematic search was conducted for guidelines in English, Dutch, Flemish, or Italian. The search was performed in multiple databases (PubMed, CancerLit, CNAHL, Cochrane Library, NHS Evidence and Google Scholar), and via other Internet resources. Hereafter, the final version of the checklist will be used to extract data from selected literature, and the same will be compiled, entered into SPSS, cleaned and analysed systematically for publication. Discussion We have together developed a comprehensive checklist in a scientifically rigorous manner to allow standardised and systematic comparison. The protocol is applicable to all guidelines on palliative sedation, and the approach will contribute to rigorous and systematic comparison of international guidelines on any challenging topic such as this. Results from the study will provide valuable insights into common core elements and differences between the selected guidelines, and the extent to which recommendations are derived from, or match those in the EAPC framework. The outcomes of the study will be disseminated via peer-reviewed journals and directly to appropriate audiences.
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Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands ; End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ; European Palliative Care Research Center, Trondheim Norway, EAPC Research Network, Milan, Italy
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster LA1 4YG, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Vrije University Medical Center, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Lieve Van Den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Vrije Universiteit Brussel (VUB), Brussels, Belgium ; Department of Family Medicine, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Abarshi EA, Papavasiliou ES, Preston N, Brown J, Payne S. The complexity of nurses' attitudes and practice of sedation at the end of life: a systematic literature review. J Pain Symptom Manage 2014; 47:915-925.e11. [PMID: 24075400 DOI: 10.1016/j.jpainsymman.2013.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 06/01/2013] [Accepted: 06/14/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Sedation is administered to some palliative care patients at the end of their life. Nurses play an important role in this practice. OBJECTIVES To systematically review the evidence on nurses' attitudes and practice of end-of-life sedation. METHODS We searched eight electronic databases, four key palliative care journals, and reference lists for empirical studies published in English, between 1990 and 2012, on nurses and their attitudes toward and practice of sedation until a patient's death. A total of 10 studies met the inclusion criteria. RESULTS Data were generated from 7515 nurses in four main settings (specialized palliative care unit, home, nursing home, and acute hospital) from seven countries (Belgium, Canada, Japan, The Netherlands, Norway, U.K., and U.S.). On average, the quality of the evidence was good; hence, we analyzed all selected studies. Based on the findings from a previous review, we categorized the emerging themes into: 1) important factors leading to the patient receiving palliative sedation (PS), 2) nurses' attitudes toward PS, and 3) nurses' experience of PS at the end of a patient's life. In general, nurses had a positive but cautious attitude toward the practice of PS. Most saw it as a last resort treatment for relieving suffering and refractory symptoms, and its practice was often influenced by their level of education, expertise, and the roles they played per setting. CONCLUSION Most nurses administered sedation until death only within the given circumstances because of the anticipatory benefits in controlling refractory symptoms and suffering. Some of them experienced burdens during PS delivery; these could be supported by operational guidelines and task-related training.
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Affiliation(s)
- Ebun A Abarshi
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom.
| | | | - Nancy Preston
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
| | - Jayne Brown
- Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, United Kingdom
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, United Kingdom
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9
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Sizoo EM, Grisold W, Taphoorn MJB. Neurologic aspects of palliative care: the end of life setting. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1219-1225. [PMID: 24365413 DOI: 10.1016/b978-0-7020-4088-7.00081-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As there are, to date, few curative treatment options for many neurologic diseases, end of life (EOL) care is an important aspect of the treatment of neurologic patients. In the EOL phase, treatment should be aimed at relieving symptoms, maintaining quality of life, and facilitating a peaceful and dignified way of dying. Common signs and symptoms in the EOL phase of neurologic patients are raised intracranial pressure, seizures, confusion, cognitive deficits, and impaired motor function. Supportive treatment of these symptoms (such as analgesic drugs, dexamethasone, antiepileptic and neuroleptic drugs) is of major importance to maintain quality of life as long as possible. Another key aspect of EOL care is EOL decision making, such as withholding or withdrawing life-sustaining treatment, and palliative sedation. The main goal of EOL decision making is the prevention and relief of suffering, even if this might hasten death. Especially in advanced stages of many neurologic diseases, confusion, cognitive deficits, communication deficits, and decreasing levels of consciousness may impair the competence of patients to participate in EOL decision making. Given that patient autonomy is increasingly essential, advance care planning (ACP) at an early stage of the disease should be considered.
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Affiliation(s)
- Eefje M Sizoo
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Wolfgang Grisold
- Department of Neurology, Kaiser Franz Josep Hospital, Vienna, Austria
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Lambeth S, Schapiro S, Bernacky B, Wilkerson G. Establishing 'quality of life' parameters using behavioural guidelines for humane euthanasia of captive non-human primates. Anim Welf 2013; 22:429-435. [PMID: 25505822 DOI: 10.7120/09627286.22.4.429] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic pain and distress are universally accepted conditions that may adversely affect an animal's quality of life (QOL) and lead to the humane euthanasia of an animal. At most research institutions and zoological parks in the USA, a veterinarian, who has physically examined the animal and reviewed the clinical records, ultimately decides when an animal has reached a humane endpoint. To aid in the difficult process of interpreting pain and distress, we have developed specific behavioural guidelines, in addition to standard clinical information, to help define unique characteristics and traits of primates to assess and promote discussion of an individual primate's QOL, and thereby, to assist in the decision-making process regarding euthanasia. These guidelines advocate the creation of a QOL team when the animal is diagnosed with a life-threatening or debilitating chronic condition, or at the time the animal is entered into a terminal study. The team compiles a list of characteristics unique to that individual animal by utilising a questionnaire and a behavioural ethogram. This list enables the team to quantitatively assess any deviations from the established normal behavioural repertoire of that individual. Concurrently, the QOL team determines the number of behavioural deviations that are needed to trigger an immediate discussion of the necessity for humane euthanasia of the animal. The team remains intact once created, and revisits the animal's condition as frequently as deemed necessary. This process improves animal welfare by continuing the quest to optimally define QOL for captive primates, and potentially for all captive animals.
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Affiliation(s)
- Sp Lambeth
- Department of Veterinary Sciences, University of Texas MD Anderson Cancer Center, 650 Coolwater Drive, Bastrop, TX 78602, USA
| | - Sj Schapiro
- Department of Veterinary Sciences, University of Texas MD Anderson Cancer Center, 650 Coolwater Drive, Bastrop, TX 78602, USA
| | - Bj Bernacky
- Department of Veterinary Sciences, University of Texas MD Anderson Cancer Center, 650 Coolwater Drive, Bastrop, TX 78602, USA
| | - Gk Wilkerson
- Department of Veterinary Sciences, University of Texas MD Anderson Cancer Center, 650 Coolwater Drive, Bastrop, TX 78602, USA
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11
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Melia KM. When the body is past fixing: caring for bodies, caring for people. J Clin Nurs 2013; 23:616-22. [DOI: 10.1111/jocn.12380] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Kath M Melia
- School of Health in Social Science; University of Edinburgh; Edinburgh UK
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12
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Shlamovitz GZ, Elsayem A, Todd KH. Ketamine for Palliative Sedation in the Emergency Department. J Emerg Med 2013; 44:355-7. [DOI: 10.1016/j.jemermed.2012.08.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 02/22/2012] [Accepted: 08/24/2012] [Indexed: 11/16/2022]
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Arevalo JJ, Rietjens JA, Swart SJ, Perez RSGM, van der Heide A. Day-to-day care in palliative sedation: survey of nurses' experiences with decision-making and performance. Int J Nurs Stud 2012; 50:613-21. [PMID: 23102504 DOI: 10.1016/j.ijnurstu.2012.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 09/30/2012] [Accepted: 10/04/2012] [Indexed: 11/24/2022]
Abstract
CONTEXT Continuous palliative sedation has been the focus of extensive international debates in the field of end-of-life decision making. Although nurses may be important participants in the performance of continuous palliative sedation, research has focused primarily on the role and experience of physicians. Nurses' experiences differ from that of physicians; they more often describe that continuous palliative sedation is used with the intention of hastening death and to have experienced serious emotional burden. Therefore, it is important to understand the experience of nurses in continuous palliative sedation. OBJECTIVE To describe nurses' experiences with the decision-making and performance of continuous palliative sedation in terminally ill patients. METHODS Cross-sectional study. In 2008, a structured questionnaire was sent to 576 nurses in six professional home care organizations, ten units for palliative care in nursing homes and in-patient hospices and seven hospitals in the western region of the Netherlands. Respondents provided information about the last patient receiving continuous palliative sedation whom they had cared for. RESULTS Two-hundred seventy-seven questionnaires were returned and 199 (71.84%) reported a case of continuous palliative sedation. Nurses felt involved in the decision to use sedation in 84% of cases, albeit to a lesser extent in home care (68.75%, p=0.002). They agreed with the performance of continuous palliative sedation in 95.97% of cases and they proposed the use of continuous palliative sedation in 16.16%. Nurses were present at the start of sedation in 81.40% of cases and reported physicians to be present in 45.22%. In 72.77%, arrangements had been made among caregivers about the coordination of health care regarding the sedation. CONCLUSION Nurses seem to play an important role in the use of continuous sedation. This role is mainly supportive toward physicians and patients during the decision-making process, but shifts to an active performance of sedation, particularly in settings where they explicitly participate as members of a team. Nurses could develop the practice of palliative sedation by anticipating procedural obstacles in the performance of continuous palliative sedation. We recommend them to become more active participants in the decision-making to improve the care of patients receiving continuous palliative sedation.
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Affiliation(s)
- Jimmy J Arevalo
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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Patel B, Gorawara-Bhat R, Levine S, Shega JW. Nurses' attitudes and experiences surrounding palliative sedation: components for developing policy for nursing professionals. J Palliat Med 2012; 15:432-7. [PMID: 22500480 DOI: 10.1089/jpm.2011.0336] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nurses play an integral role in providing care for patients with end of life (EOL) symptoms refractory to conventional treatments and that may necessitate palliative sedation (PS). A paucity of research on nurses' attitudes, knowledge, and experience with PS exists, despite nurses being instrumental in evaluating its appropriateness and carrying out the care plan. OBJECTIVE The objective of the study was to elicit nurses' perspectives and conceptualizations of knowledge and skills needed to administer PS in order to inform development of a hospital policy that addresses identified concerns. METHODS Four focus groups were conducted with nurses likely to have had exposure to PS (oncology, intensive care, and hospice) at an academic medical center. Focus groups were audiotaped, transcribed verbatim, and coded for salient themes. Grounded theory principles were used for the analysis. RESULTS Among the four focus groups (n=31), 87% were female, 58% between the ages of 36 and 55, and more than 40% reported 10-plus years of providing patient care. Five domains emerged as important in developing a PS policy: 1) ability to define PS; 2) criterion for using PS; 3) skill set for administering PS; 4) policy and procedural guidelines; and 5) education on PS and EOL care. CONCLUSIONS Nurses identified knowledge, skills, and guidelines as key considerations for implementing PS. Comprehensive policies along with adequate training are needed to expand the availability of PS in acute care hospitals and hospice programs.
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Affiliation(s)
- Bansari Patel
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, IL 60637, USA.
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Hahn MP. Review of palliative sedation and its distinction from euthanasia and lethal injection. J Pain Palliat Care Pharmacother 2012; 26:30-9. [PMID: 22448939 DOI: 10.3109/15360288.2011.650353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.
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Affiliation(s)
- Michael P Hahn
- Respiratory Care, Loma Linda University Children's Hospital, Loma Linda, California 92354, USA.
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16
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Decision-making in the end-of-life phase of high-grade glioma patients. Eur J Cancer 2011; 48:226-32. [PMID: 22153216 DOI: 10.1016/j.ejca.2011.11.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/03/2011] [Accepted: 11/07/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND During the disease course of high-grade glioma (HGG) patients, the goal of therapy eventually shifts from primarily life-prolongation to primarily sustaining the quality of life as good as possible. End-of-life care is aimed at prolongation of life with good quality, but inevitably also may require medical decisions for prevention and relief of suffering with a potential life shortening effect. Few data are available on this end-of-life decision (ELD) making process in HGG patients, with decreased consciousness, confusion or cognitive deficits preventing them to participate. In this study the ELD-making process in HGG patients is described. METHODS Physicians and relatives of a cohort of 155 deceased HGG patients were identified to fill in a questionnaire regarding the end-of-life conditions (patients' ELD preferences, patients' competence) and ELD-making (forgoing treatment and the administration of drugs with a potential life-shortening effect) for their patient or relative. Data were analysed with descriptive statistics. FINDINGS Of 101 patients, physicians completed surveys including questions about ELDs (62% response rate). More than half of the patients relatively early became incompetent to make decisions due to delirium, cognitive deficits and/or decreasing consciousness. In 40% of patients the physician did not discuss ELD preferences with his/her patient. At least one ELD was made in 72% of patients, most often this comprised the withdrawal of dexamethasone. Palliative sedation was performed in 30% of patients and physician assisted death in 7%. INTERPRETATION ELDs are common practises amongst HGG patients, although their preferences towards ELDs are frequently unknown to the physician. Because the majority of patients become incompetent towards death, participation in ELD-making is only possible with advanced care planning. Hence, timely discussion of ELD preferences is encouraged.
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Inghelbrecht E, Bilsen J, Mortier F, Deliens L. Continuous deep sedation until death in Belgium: a survey among nurses. J Pain Symptom Manage 2011; 41:870-9. [PMID: 21545951 DOI: 10.1016/j.jpainsymman.2010.07.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 07/29/2010] [Accepted: 07/29/2010] [Indexed: 11/28/2022]
Abstract
CONTEXT Continuous deep sedation (CDS) is a subject of important debate, but until now nurses have rarely been questioned about their involvement and perceptions. OBJECTIVES To study the communication process between nurses and patients, relatives, or physicians before starting CDS, and how nurses perceive this end-of-life practice. METHODS In 2007, we surveyed 1678 nurses in Flanders, Belgium, who, in an earlier survey, had reported caring for one or more patients who received an end-of-life decision within the previous year. Nurses were surveyed about their most recent case. RESULTS The response rate was 75.8%: 250 nurses reported a case of CDS (64.4% hospital, 18.4% home, and 17.2% nursing home). In, respectively, 25.8% and 75.4%, the patient and relatives had communicated with the nurse about the CDS. In 17.6%, there was no communication between the nurse and the physician about the CDS; in 29.1%, the physician and nurse only exchanged information; and in 23.4%, they made the decision jointly. Making the decision jointly was associated with a more positive evaluation of the cooperation with the physician (adjusted odds ratio 10.9 and 95% confidence interval 3.0, 39.2). Nurses perceived CDS as partly intended to hasten death partially in 48.4% and explicitly in 28.4% of cases, estimating possible or certain life shortening in 95.6%. CONCLUSION Nurses in different health care settings are often involved in communication about CDS. They see it mainly as a practice intended to hasten death, with a life-shortening effect; guidelines should recommend clear discussions between caregivers in which the physician states the purpose and estimated effect of the decision.
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Affiliation(s)
- Els Inghelbrecht
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
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18
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Brinkkemper T, Klinkenberg M, Deliens L, Eliel M, Rietjens JA, Zuurmond WW, Perez RS. Palliative sedation at home in the Netherlands: a nationwide survey among nurses. J Adv Nurs 2011; 67:1719-28. [DOI: 10.1111/j.1365-2648.2011.05614.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Lindblad A, Juth N, Fürst CJ, Lynöe N. Continuous deep sedation, physician-assisted suicide, and euthanasia in Huntington's disorder. Int J Palliat Nurs 2011; 16:527-33. [PMID: 21135785 DOI: 10.12968/ijpn.2010.16.11.80019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To investigate the attitudes among Swedish physicians and the general public towards continuous deep sedation (CDS) as an alternative treatment for a competent, not imminently dying patient with Huntington's disorder requesting physician-assisted suicide (PAS) and euthanasia. DESIGN A questionnaire was distributed to 1200 physicians in Sweden and 1201 individuals in Stockholm. It consisted of three parts: 1) A vignette about a competent patient with Huntington's disease requesting PAS. When no longer competent, relatives request euthanasia on behalf of the patient. Responders were asked about their attitudes towards these requests and whether CDS would be an acceptable alternative. 2) General questions about PAS and euthanasia. 3) Background variables. RESULTS The response rate was 56% (physicians) and 52% (general public). The majority of the general public and a fairly large proportion of physicians reported more liberal views on CDS than are expressed in current Swedish and international recommendations. CONCLUSION In light of the results, we suggest that there is a need for a broader discussion about the recommendations for CDS, with a special focus on the needs of patients with progressive neurodegenerative disorders.
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Affiliation(s)
- Anna Lindblad
- Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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20
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Sedierung in der Palliativmedizin*: Leitlinie für den Einsatz sedierender Maßnahmen in der Palliativversorgung. Schmerz 2010; 24:342-54. [DOI: 10.1007/s00482-010-0948-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23:581-93. [PMID: 19858355 DOI: 10.1177/0269216309107024] [Citation(s) in RCA: 403] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Nathan I Cherny
- Shaare Zedek Medical Center, Department of Oncology, Jerusalem, Israel.
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22
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Venke Gran S, Miller J. Norwegian nurses’ thoughts and feelings regarding the ethics of palliative sedation. Int J Palliat Nurs 2008; 14:532-8. [DOI: 10.12968/ijpn.2008.14.11.31757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Jean Miller
- College of Nursing University of Rhode Island, United States
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24
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Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Support Care Cancer 2008; 17:53-9. [DOI: 10.1007/s00520-008-0459-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 04/09/2008] [Indexed: 01/21/2023]
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The National Consensus Project and National Quality Forum Preferred Practices in Care of the Imminently Dying. J Hosp Palliat Nurs 2007. [DOI: 10.1097/01.njh.0000299314.99514.c2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Simon A, Kar M, Hinz J, Beck D. Attitudes towards terminal sedation: an empirical survey among experts in the field of medical ethics. BMC Palliat Care 2007; 6:4. [PMID: 17437628 PMCID: PMC1855046 DOI: 10.1186/1472-684x-6-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 04/16/2007] [Indexed: 11/28/2022] Open
Abstract
Background "Terminal sedation" regarded as the use of sedation in (pre-)terminal patients with treatment-refractory symptoms is controversially discussed not only within palliative medicine. While supporters consider terminal sedation as an indispensable palliative medical treatment option, opponents disapprove of it as "slow euthanasia". Against this background, we interviewed medical ethics experts by questionnaire on the term and the moral acceptance of terminal sedation in order to find out how they think about this topic. We were especially interested in whether experts with a professional medical and nursing background think differently about the topic than experts without this background. Methods The survey was carried out by questionnaire; beside the provided answering options free text comments were possible. As test persons we chose the 477 members of the German Academy for Ethics in Medicine, an interdisciplinary society for medical ethics. Results 281 completed questionnaires were returned (response rate = 59%). The majority of persons without medical background regarded "terminal sedation" as an intentional elimination of consciousness until the patient's death occurs; persons with a medical background generally had a broader understanding of the term, including light or intermittent forms of sedation. 98% of the respondents regarded terminal sedation in dying patients with treatment-refractory physical symptoms as acceptable. Situations in which the dying process has not yet started, in which untreatable mental symptoms are the indication for terminal sedation or in which life-sustaining measures are withdrawn during sedation were evaluated as morally difficult. Conclusion The survey reveals a great need for research and discussion on the medical indication as well as on the moral evaluation of terminal sedation. Prerequisite for this is a more precise terminology which describes the circumstances of the sedation.
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Affiliation(s)
- Alfred Simon
- Academy for Ethics in Medicine, Georg-August-University, Goettingen, Germany
| | - Magdalene Kar
- Department of Medical Ethics and History of Medicine, Georg-August-University, Goettingen, Germany
| | - José Hinz
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August-University, Goettingen, Germany
| | - Dietmar Beck
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, Georg-August-University, Goettingen, Germany
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Carmona Jiménez AM, González M, Vélez Ángel MC, Krikorian A. Impacto familiar de la sedación paliativa en pacientes terminales desde la perspectiva del cuidador principal. ACTA ACUST UNITED AC 1970. [DOI: 10.5209/psic.54441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objetivo: Describir el impacto familiar de la sedación paliativa en pacientes con enfermedad avanzada terminal ya fallecidos, desde la percepción del cuidador principal.Método: Estudio cualitativo de enfoque fenomenológico. Se realizaron entrevistas semi-estructuradas a diez cuidadores principales de pacientes con enfermedad terminal fallecidos bajo sedación paliativa, que fueron atendidos por cuidados paliativos en una institución oncológica de Medellín, Colombia entre enero y marzo de 2015. Se analizó la información a partir de categorías preestablecidas: significado, cambios emocionales, cambios estructurales y duelo.Resultado: Los cuidadores no tenían ningún conocimiento previo sobre la sedación. Todos reportan que fueron informados sobre el objetivo y los cambios físicos que podía presentar el paciente; sin embargo, la mitad de ellos refirieron que esta información no fue suficiente para comprender el proceso que enfrentaban. Manifestaron diversos sentimientos (alivio, duda, impotencia, tristeza) antes, durante y después de la sedación. Respecto a los cambios estructurales, la mayoría de las familias se reorganizaron y facilitaron el acompañamiento y cuidado al paciente refiriendo fortalecimiento de las relaciones familiares. Finalmente, se encontró que los cuidadores percibieron que la sedación paliativa facilita el duelo, al aliviar el sufrimiento y permitiendo una buena muerte.Conclusiones: Los cuidadores evalúan la experiencia de sedación como positiva y satisfactoria para aliviar el sufrimiento de su ser querido y el de su familia. Igualmente, facilita el proceso de duelo por la construcción positiva de alivio en torno a la experiencia vivida como familia, fortaleciendo sus relaciones y recordando una buena muerte para su paciente
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