The practices and attitudes of nurses regarding palliative sedation: A scoping review

Navigating end-of-life decision-making in nursing: a systematic review of ethical challenges and palliative care practices

OBJECTIVES

This systematic review aimed to synthesize evidence on the ethical dilemma's nurses encounter in end-of-life care and effective palliative care practices. The objectives were to understand key ethical issues, evaluate communication and decision-making strategies, and identify approaches to support nurses and patients.

METHODS

A comprehensive search of major databases was conducted according to the PRISMA guidelines. Studies directly relating to nursing ethics, challenges in end-of-life decision-making, and palliative care practices were included. The risk of bias was assessed using ROBVIS-II. Data on ethical issues, palliative interventions, and outcomes was extracted and analyzed thematically.

RESULTS

22 studies met the inclusion criteria. Key themes that emerged were: (1) Effective communication and involving patients in decision-making are essential but complex. (2) Nurses face dilemmas around balancing autonomy, beneficence and relational issues. (3) Integrating palliative care principles enhances symptom management and aligns care with patient values. (4) Education and organizational support are needed to equip nurses with skills and coping strategies.

CONCLUSION

Navigating end-of-life care requires addressing interconnected ethical, communication and support needs. While studies provided insights, further research is required on cultural competence training, standardized education programs and longitudinal evaluations.

The Attitudes and Experiences of Hospice Nurses Regarding Palliative Sedation: A Cross-Sectional Descriptive Study

Background: Despite the global acceptance of palliative sedation, China's engagement in this field remains comparatively restricted. There exists a scarcity of information regarding the attitudes and experiences of hospice nurses concerning palliative sedation. Objectives: This survey aimed at investigating the attitudes of Chinese hospice nurses toward palliative sedation, as well as their practices in palliative sedation. Design: A cross-sectional descriptive study. Setting/Subjects: In 2023, the survey on palliative sedation was introduced during the opening ceremony of the largest National Symposium on New Advances in Hospice Nursing in China. Subsequently, the study questionnaire was disseminated through email to a cohort of 806 hospice nurses attending the conference. Measurements/Results: The statistical analysis was based on 641 valid responses. Among them, 508 had no experience with palliative sedation, while only 133 had such experience. Around 92.5% of hospice nurses with experience in palliative sedation agreed with the physician's instructions to begin palliative sedation. Nurses were present at the start of sedation in nearly all cases (97.0%), and most doctors (79.7%) and family members (82.0%) were also present. However, 8.3% of them perceived that there was no difference between palliative sedation and euthanasia. Furthermore, 13.5% of participants believed that the purpose of palliative sedation was to hasten death. Conclusions: Hospice nurses play a crucial role in the process of palliative sedation, yet they also face significant challenges. It suggests that there is an urgent need in China for the development of consensus or guidelines for palliative sedation to clarify the roles of team members, including hospice nurses.

[PAL-PRAT study: Healthcare workers' knowledge and perception of palliative practices in a Cancer Center]

INTRODUCTION

The issue of end-of-life care is the subject of a sensitive debate in French society, particularly regarding the possibility for certain patients to have access to medical assistance in dying. The aim of this study was to assess the knowledge and opinion of healthcare providers on the care practices for patients at the end of life, as well as to highlight any specificities in their discourse.

METHOD

A survey of healthcare providers' opinions, composed of closed and open questions, that were analyzed using a lexicometric approach, was distributed in a cancer center.

RESULTS

The results of the study reveal a good knowledge of the different procedures. Professionals considered that advance directives should be systematically collected; a majority of them differentiated euthanasia from deep continuous sedation and perceived the latter as a means of relieving patients' suffering without inducing death. The different procedures related to the active assistance in dying were known by a majority of professionals and the survey did not identify a dominant trend concerning the will to practice euthanasia if the legal framework allowed it. Half of the participants considered their training insufficient, indicating the need to fill this gap.

DISCUSSION

This survey underlines the importance of training and support for the professionals caring for patients in palliative situation and their relatives in France.

Sedation practices in palliative care services across France: a nationwide point-prevalence analysis

OBJECTIVES

Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service.

METHODS

We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study.

RESULTS

In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type.

CONCLUSIONS

This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices.

Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology

BACKGROUND

In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception.

METHODS

Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter.

RESULTS

63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life.

CONCLUSION

Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.

Disentangling concepts of inappropriate polypharmacy in old age: a scoping review

INTRODUCTION

Polypharmacy is a common concern, especially in the older population. In some countries more that 50% of all individuals over 60 receive five or more drugs, most often due to multimorbidity and increased longevity. However, polypharmacy is associated with multiple adverse events, and more medication may not always be the answer. The terms "appropriate" and "inappropriate" are often used to distinguish between "much" and "too much" medications in relation to polypharmacy in research and practice, but no explicit definition exists to describe what these terms encompass. The aim of this review is to unfold the different understandings of and perspectives on (in)appropriate polypharmacy and suggest a framework for further research and practice.

METHOD

A scoping review was conducted using the framework of Arksey and O'Malley and Levac et al. Pubmed, Embase, PsycINFO, CINAHL, Cochrane database, Scopus and Web of Science were searched for references in English, Danish, Norwegian and Swedish using the search string "Polypharmacy" AND "Appropriate" OR "Inappropriate". Data was extracted on author information, aims and objectives, methodology, study population and setting, country of origin, main findings and implications, and all text including the words "appropriate," "inappropriate," and "polypharmacy." Qualitative meaning condensation analysis was used and data charted using descriptive and thematic analysis.

RESULTS

Of 3982 references, a total of 92 references were included in the review. Most references were from 2016-2021, from fields related to medicine or pharmacy, and occurred within primary and secondary healthcare settings. Based on the qualitative analysis, a framework were assembled consisting of Context, three domains (Standardization, Practices and Values & Concerns) and Patient Perspective.

CONCLUSION

Inappropriate polypharmacy is a concept loaded by its heterogeneity and the usefulness of a single definition is doubtful. Instead, the framework suggested in this article representing different dimensions of inappropriate polypharmacy may serve as an initial strategy for focusing research and practice on polypharmacy in old age.

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

Current Status and Future Directions of Research on Palliative Sedation

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.

The practices of nurses about palliative sedation on palliative care wards: A qualitative study

AIM

To describe the practices of nurses concerning palliative sedation in palliative care wards in hospitals.

DESIGN

Qualitative descriptive design.

METHODS

A total of 27 nurses were interviewed in six focus groups and one pair interview; the nurses worked on four palliative care wards in three Finnish hospitals and the interviews took place between May and November 2019. The data were analysed using inductive content analysis. The COREQ checklist was used as a guide for reporting this study.

FINDINGS

Three main categories describing nurses' practices concerning palliative sedation were identified: participation in palliative sedation decision-making, sedation implementation and monitoring and information sharing and compassionate care for the patient and relatives.

CONCLUSIONS

Nurses play a key role throughout palliative sedation on palliative care wards in hospitals. To develop the quality of care, it is recommended to specify the role of nurses in palliative sedation, increase cooperation between nurses and physicians, and enhance palliative sedation education for nurses.

Ethical dilemmas and care actions in nurses providing palliative sedation

BACKGROUND

Recently, palliative care is increasingly important, with an emphasis on the process of dying with dignity. However, nurses who care for such patients experience the associated ethical dilemmas.

OBJECTIVE

To explore the meaning of nurses' experiences in dealing with ethical dilemmas in relation to palliative sedation.

RESEARCH DESIGN

A qualitative research design was employed with a thematic analysis approach.

PARTICIPANTS AND RESEARCH CONTEXT

Using purposive sampling, 15 nurses, working at palliative care units for at least 1 year, were recruited as participants. Data were collected using unstructured in-depth interviews, and data collection and analysis was performed simultaneously.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the authors' institutional review board. All participants provided informed consent. For the face-to-face interview, the South Korean standard COVID-19 quarantine guidelines, such as mandatory masking and social distancing, were followed.

RESULTS

Dilemmas raised by patients, were related to concerns about appropriate drug dose; dilemmas raised by nurses, were related to passive care, sense of guilt for failure to predict death, and colleague's disrespectful attitudes toward patients; dilemmas from patients' families were related to demands for palliative sedation and reversal of those demands. Care actions to deal with ethical dilemmas comprised evidence-based care, person-centered thinking, reflecting on the death situation, compassion, providing explanation and help to family members.

CONCLUSION

Nurses' ethical dilemmas were pre-dominantly influenced by themselves, rather than by the patients or their families, especially if they felt they could not do their best for patients. The core concept of care actions to deal with the ethical dilemmas, was person-centered care and compassion. Then, how patients and their family members perceive person-centered care and compassion, should be further explored to improve palliative sedation.