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Kremling A, Bausewein C, Klein C, Nadolny S, Ostgathe C, Schildmann E, Ziegler K, Schildmann J. Terminological Confusion About Sedation in Palliative Care: Results of an International Online Vignette Survey. J Palliat Med 2024; 27:487-494. [PMID: 38330403 PMCID: PMC10998700 DOI: 10.1089/jpm.2023.0159] [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] [Accepted: 11/08/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Terminological problems concerning sedation in palliative care and consequences for research and clinical decision making have been reported frequently. Objectives: To gather data on the application of definitions of sedation practices in palliative care to clinical cases and to analyze implications for high-quality definitions. Design: We conducted an online survey with a convenience sample of international experts involved in the development of guidelines on sedation in palliative care and members of the European Association for Palliative Care (EAPC). Participants were asked to apply four published definitions to four case vignettes. Data were analyzed using descriptive statistics. Results: A total of 32 experts and 271 EAPC members completed the survey. The definitions were applied correctly in n = 2200/4848 cases (45.4%). The mean number of correct applications of the definitions (4 points max.) was 2.2 ± 1.14 for the definition of the SedPall study group, 1.8 ± 1.03 for the EAPC definition, 1.7 ± 0.98 for the definition of the Norwegian Medical Association, and 1.6 ± 1.01 for the definition of the Japanese Society of Palliative Medicine. The rate of correct applications for the 16 vignette-definition pairs varied between 70/303 (23.1%) and 227/303 (74.9%). The content of definitions and vignettes together with free-text comments explains participants' decisions and misunderstandings. Conclusions: Definitions of sedation in palliative care are frequently incorrectly applied to clinical case scenarios under simplified conditions. This suggests that clinical communication and research might be negatively influenced by misunderstandings and inconsistent labeling or reporting of data. Clinical Trial Registration Number: DRKS00015047.
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Affiliation(s)
- Alexander Kremling
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
| | - Carsten Klein
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stephan Nadolny
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
- Institute for Educational and Health-Care Research in the Health Sector, Hochschule Bielefeld—University of Applied Sciences and Arts, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
- Palliative Medicine, Faculty of Medicine, University of Augsburg, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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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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Gilbertson L, Savulescu J, Oakley J, Wilkinson D. Expanded terminal sedation in end-of-life care. JOURNAL OF MEDICAL ETHICS 2023; 49:252-260. [PMID: 36543531 PMCID: PMC10086483 DOI: 10.1136/jme-2022-108511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/04/2022] [Indexed: 06/17/2023]
Abstract
Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term 'Expanded TS' (ETS) can be used to describe the use of sedation at the end of life outside one or more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap.
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Affiliation(s)
- Laura Gilbertson
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Justin Oakley
- Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Newborn Care, John Radcliffe Hospital, Oxford, UK
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Kremling A, Bausewein C, Klein C, Schildmann E, Ostgathe C, Ziegler K, Schildmann J. Intentional Sedation as a Means to Ease Suffering: A Systematically Constructed Terminology for Sedation in Palliative Care. J Palliat Med 2022; 25:793-796. [PMID: 35073180 PMCID: PMC9081045 DOI: 10.1089/jpm.2021.0428] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Carsten Klein
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
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Family experience of palliative sedation therapy: proportional vs. continuous deep sedation. Support Care Cancer 2022; 30:3903-3915. [PMID: 35039967 DOI: 10.1007/s00520-021-06745-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Some patients experience intense symptoms refractory to intensive palliative care, and palliative sedation is sometimes used. Palliative sedation may be classified into proportional and continuous deep sedation (CDS). The primary aim of this study was to compare family experience between families of patients who received proportional or CDS. METHODS A multicenter questionnaire survey was conducted involving bereaved families of cancer patients who received proportional or CDS based on a sedation protocol. Overall evaluation of sedation (satisfaction, family-perceived distress, appropriateness of timing, and patient distress) and 13-item family concerns, good death, satisfaction with care, depression, quality of care, unfinished business, and balance between symptom relief and maintaining communication were measured. RESULTS Among the 2120 patients who died, 222 patients received a continuous infusion of midazolam. A sedation protocol was used in 147 patients, and questionnaires were sent to 124 families. A total of 78 responses were finally returned (proportional, 58 vs. CDS, 20). There were no significant differences in the overall evaluation, family concerns, total score of good death, satisfaction, depression, or balance between symptom relief and maintaining communication. On the other hand, some quality of care items, i.e., relationship with medical staff (P < 0.01), physical care by nurses (P = 0.04), and coordination and consistency (P = 0.04), were significantly better in the CDS group than in the proportional sedation group. Family-reported unfinished business was also better in the CDS group, with marginal significance. CONCLUSIONS Family experience of CDS was not less favorable than proportional sedation, and actually rated more favorably for some elements of quality of care and unfinished business.
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Yokomichi N, Yamaguchi T, Maeda I, Mori M, Imai K, Shirado Naito A, Yamaguchi T, Terabayashi T, Hiratsuka Y, Hisanaga T, Morita T. Effect of continuous deep sedation on survival in the last days of life of cancer patients: A multicenter prospective cohort study. Palliat Med 2022; 36:189-199. [PMID: 35067124 DOI: 10.1177/02692163211057754] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Continuous deep sedation is ethically controversial with respect to whether it shortens a patient's life. AIM To examine whether continuous deep sedation shortens patient survival from the day of Palliative Performance Scale decline to 20 (PPS20). DESIGN A part of a multicenter prospective cohort study (EASED study). SETTING/PARTICIPANTS We recruited consecutive adult patients with advanced cancer admitted to 23 participating palliative care units in 2017 in Japan. We compared survival from PPS20 between those who did and did not receive continuous deep sedation. Continuous deep sedation was defined as the continuous administration of sedative medication with the intention to keep a patient continuously unconscious to alleviate otherwise uncontrollable symptoms, but the dose of sedatives was adjusted to achieve adequate symptom relief for each patient. The propensity score-weighting method was used to control for potential confounders, and five sensitivity analyses were performed. RESULTS A total of 1926 patients were enrolled. Patients discharged alive were excluded, and we analyzed 1625 patients of whom 156 (9.6%) received continuous deep sedation. Median survival from PPS20 of 1625 patients was 81 h (95% CI: 77-88). The RASS scores decreased to ⩽-4 was 66% at 24 h. Continuous deep sedation was not associated with a significant survival risk (adjusted hazard ratio: 1.06, 95% CI: 0.85-1.33). All sensitivity analyses, including continuous deep sedation defined as the RASS score was ⩽-4 achieved the essentially the same results. CONCLUSIONS Continuous deep sedation with careful dose adjustment was not associated with shorter survival in the last days of life in patients with advanced cancer.
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Affiliation(s)
- Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Osaka, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | | | | | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Imai K, Morita T, Yokomichi N, Kawaguchi T, Kohara H, Yamaguchi T, Kikuchi A, Odagiri T, Watanabe YS, Kamura R, Maeda I, Kawashima N, Ito S, Baba M, Matsuda Y, Oya K, Kaneishi K, Hiratsuka Y, Naito AS, Mori M. Efficacy of Proportional Sedation and Deep Sedation Defined by Sedation Protocols: A Multicenter, Prospective, Observational Comparative Study. J Pain Symptom Manage 2021; 62:1165-1174. [PMID: 34118372 DOI: 10.1016/j.jpainsymman.2021.06.005] [Citation(s) in RCA: 3] [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: 02/12/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE To investigate the efficacy of two types of palliative sedation: proportional and deep sedation, defined by sedation protocols. METHODS From a multicenter prospective observational study, we analyzed the data of those patients who received the continuous infusion of midazolam according to the sedation protocol. The primary endpoint was goal achievement at 4 hours: in proportional sedation, symptom relief (Integrated Palliative care Outcome Scale: IPOS ≤ 1) and absence of agitation (modified Richmond Agitation-Sedation Scale: RASS ≤ 0); in deep sedation, the achievement of deep sedation (RASS ≤ -4). Secondary endpoints included deep sedation as a result of proportional sedation, communication capacity (Communication Capacity Scale item 4 ≤ 2), IPOS and RASS scores, and adverse events. RESULTS A total of 81 patients from 14 palliative care units were analyzed: proportional sedation (n = 64) and deep sedation (n = 17). At 4 hours, the goal was achieved in 77% (n = 49; 95% confidence interval: 66-87) with proportional sedation; and 88% (n = 15; 71-100) with deep sedation. Deep sedation was necessary in 45% of those who received proportional sedation. Communication capacity was maintained in 34% with proportional sedation and 10% with deep sedation. IPOS decreased from 3.5 to 0.9 with proportional sedation, and 3.5 to 0.4 with deep sedation; RASS decreased from +0.3 to -2.6, and +0.4 to -4.2, respectively. Fatal events related to the treatment occurred in 2% (n = 1) with proportional and none with deep sedation. CONCLUSION Proportional sedation achieved satisfactory symptom relief while maintaining some patients' consciousness, and deep sedation achieved good symptom relief while the majority of patients lost consciousness.
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Affiliation(s)
- Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital (K.I.), Hamamatsu, Japan.
| | - Tatsuya Morita
- Division of Palliative and Supportive Care (T.M., N.Y., M.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care (T.M., N.Y., M.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy (T.K.), Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Hiroyuki Kohara
- Department of Internal Medicine (H.K.), Hatsukaichi Memorial Hospital, Hatsukaichi, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care (T.Y.), Konan Medical Center, Kobe, Japan
| | - Ayako Kikuchi
- Department of Oncology and Palliative Medicine (A.K.), Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Takuya Odagiri
- Komaki City Hospital (T.O.), Palliative Care, Komaki, Japan
| | - Yuki Sumazaki Watanabe
- Department of Palliative Medicine (Y.S.W.), National Cancer Center Hospital East, Kashiwa, Japan
| | - Rena Kamura
- Hospice (R.K.), Yodogawa Christian Hospital, Osaka, Japan
| | - Isseki Maeda
- Department of Palliative Care (I.M.), Senri-Chuo Hospital, Toyonaka, Japan
| | - Natsuki Kawashima
- Department of Palliative Medicine (N.K.), Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Satoko Ito
- Hospice (S.I.), The Japan Baptist Hospital, Kyoto, Japan
| | - Mika Baba
- Department of Palliative Medicine (M.B.), Suita Tokushukai Hospital, Suita, Japan
| | - Yosuke Matsuda
- Palliative Care Department (Y.M.), St. Luke's International Hospital, Tokyo, Japan
| | - Kiyofumi Oya
- Transitional and Palliative Care (K.O.), Aso Iizuka Hospital, Iizuka, Japan
| | - Keisuke Kaneishi
- Department of Palliative Care Unit (K.K.), JCHO Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine (Y.H.), Tohoku University School of Medicine, Sendai, Japan
| | - Akemi Shirado Naito
- Department of Palliative Care (A.S.N.), Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care (T.M., N.Y., M.M.), Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Ahn HK, Ahn HY, Park SJ, Hwang IC. Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:254-260. [PMID: 37674644 PMCID: PMC10180067 DOI: 10.14475/jhpc.2021.24.4.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/30/2021] [Indexed: 09/08/2023]
Abstract
Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.
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Affiliation(s)
- Hee Kyung Ahn
- Oncology Division, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Korea
| | | | - In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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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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Bretonniere S, Fournier V. Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It. J Pain Symptom Manage 2021; 62:e13-e19. [PMID: 33819514 DOI: 10.1016/j.jpainsymman.2021.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT The French parliament passed a groundbreaking law in 2016, opening a right for patients to access continuous and deep sedation until death (CDS) at the end of life, under conditions. Parliamentarians' goal was to consolidate patients' rights whilst avoiding legislating on medical aid in dying. OBJECTIVES To conduct a first national retrospective survey on CDS to evaluate the number of CDS requested, proposed and performed in 2017 and to elicit qualitative data from physicians on the practice and on the terms used by patients to refer to CDS. METHODS Early 2018, an online survey was sent to all French hospitals, nursing homes, hospital at homes services and general practitioners (GPs). Descriptive statistics and qualitative inductive content analysis were used to analyze the data and comments of respondents. RESULTS The qualitative data show that respondents generally approve the law on CDS as it sets a legal framework; nonetheless, there is a persistent controversy about CDS vs. euthanasia for some physicians in all settings. GPs reported limited access to midazolam and the difficulty in organizing multidisciplinary procedures as major constraints. In hospital settings in particular, differentiating CDS from other sedation practices is uneasy. All physicians reported patients use multiple elements of language to request CDS. CONCLUSION After the law was passed in France, CDS were requested, proposed and performed in all medical settings, in nursing homes, at home. The qualitative data presented here show the relevance of exploring physicians' reflexive stances on this practice in different settings and within the context of a patient-physician relationship marked by a new patient's right. The study highlights the wide range of elements of language used by patients at the end of life, as understood by respondent physicians to mean a request for CDS and underscores the polymorphous meaning of CDS.
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Affiliation(s)
- Sandrine Bretonniere
- Centre national des soins palliatifs et de la fin de vie (S.B.), Paris Cedex 19, France.
| | - Veronique Fournier
- Centre national des soins palliatifs et de la fin de vie, Centre d'éthique clinique, Assistance publique-Hôpitaux de Paris (V.F.), Paris, France
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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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13
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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) - a particular form of sedation - has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. METHODS We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. RESULTS We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called 'rapid CDSUD', 'gradual CDSUD', 'temporary sedation' and 'intermittent sedation'. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, 'temporary' or 'intermittent sedation', although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). CONCLUSION These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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14
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Heijltjes MT, van Thiel GJMW, Rietjens JAC, van der Heide A, de Graeff A, van Delden JJM. Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature. J Pain Symptom Manage 2020; 60:828-846.e3. [PMID: 32599152 DOI: 10.1016/j.jpainsymman.2020.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/14/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients. OBJECTIVE To gain insight in developments in the use of CSD in various countries and subpopulations. METHODS We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death. RESULTS We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families. CONCLUSIONS The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.
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Affiliation(s)
- Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, The Netherlands and Academic Hospice Demeter, De Bilt, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Mori M, Yamaguchi T, Matsuda Y, Suzuki K, Watanabe H, Matsunuma R, Kako J, Imai K, Usui Y, Matsumoto Y, Hui D, Currow D, Morita T. Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer. ESMO Open 2020; 5 Suppl 1:e000603. [PMID: 33558034 PMCID: PMC7046422 DOI: 10.1136/esmoopen-2019-000603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/01/2019] [Accepted: 02/04/2020] [Indexed: 12/14/2022] Open
Abstract
Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | | | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yuko Usui
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Currow
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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16
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Kremling A, Schildmann J. What do you mean by "palliative sedation"? : Pre-explicative analyses as preliminary steps towards better definitions. BMC Palliat Care 2020; 19:147. [PMID: 32967659 PMCID: PMC7513316 DOI: 10.1186/s12904-020-00635-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Kremling
- Institute of History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Madgeburger Straße 8, Halle (Saale), 06112 Germany
| | - Jan Schildmann
- Institute of History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Madgeburger Straße 8, Halle (Saale), 06112 Germany
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17
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Benítez-Rosario MA, Ascanio-León B. Palliative sedation: beliefs and decision-making among Spanish palliative care physicians. Support Care Cancer 2020; 28:2651-2658. [PMID: 31637516 DOI: 10.1007/s00520-019-05086-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe physician attitudes to deep palliative sedation. METHODS A nationwide e-survey of Spanish palliative care specialists was performed using vignettes which described patients close to death with intractable symptoms. Sedation levels were defined according to the Richmond Agitation-Sedation Scale. Multivariate analyses were performed to assess the explanatory factors involved in decision-making. RESULTS Responses of 292 palliative care specialists were analyzed (response rate 40%). Ninety-four percent, 87%, and 81% of the respondents supported the use of palliative sedation in cases of irreversible refractory symptoms as hyperactive delirium and dyspnea at rest secondary to lung cancer and GOLD stage IV COPD; 60% agreed with the use of palliative sedation in cases of existential suffering. Logistic regression analysis found as the explanatory factor in not performing palliative sedation the physicians' belief that sedation therapy constitutes undercover euthanasia (OR = 12, p < 0.01). Around 80% of physicians who decided on palliative sedation chose deep/complete sedation for every vignette; there were no common explanatory factors for decision-making for every vignette. The belief that sedation therapy equates to undercover euthanasia justifies not performing deep sedation in cases of irreversible refractory agitated delirium (OR = 7) and irreversible intractable dyspnea (OR = 6). Physician background in palliative care and sedation were associated with the selection of deep/complete sedation in cases of refractory delirium and cancer-associated dyspnea. CONCLUSIONS Spanish palliative physicians generally agree with the use of deep sedation as a proportionate treatment in dying patients with refractory symptoms. Decision-making is associated with physician beliefs regarding euthanasia and with the physician's background in palliative care and sedation.
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Affiliation(s)
- Miguel Angel Benítez-Rosario
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain.
| | - Belén Ascanio-León
- Palliative Care Unit, La Candelaria Hospital, Canary Health Service, Facultad de Medicina, Universidad de La Laguna, Crtra del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
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18
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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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Imai K, Morita T, Akechi T, Baba M, Yamaguchi T, Sumi H, Tashiro S, Aita K, Shimizu T, Hamano J, Sekimoto G, Maeda I, Shinjo T, Nagayama J, Hayashi E, Hisayama Y, Inaba K, Abo H, Suga A, Ikenaga M. The Principles of Revised Clinical Guidelines about Palliative Sedation Therapy of the Japanese Society for Palliative Medicine. J Palliat Med 2020; 23:1184-1190. [PMID: 32283043 DOI: 10.1089/jpm.2019.0626] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: When the suffering of a terminally ill patient is intolerable and refractory, sedatives are sometimes used for symptom relief. Objective: To describe the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Design: Consensus methods using the Delphi technique were used. Results: The main principles of the guidelines that were newly defined or developed are as follows: (1) palliative sedation was defined as "administration of sedatives for the purpose of alleviating refractory suffering" (excluding the aim of reducing patient consciousness); (2) palliative sedation was classified according to the method of administration of sedatives: respite sedation versus continuous sedation (including (continuous) proportional sedation and continuous deep sedation); (3) a description of state-of-the-art recommended treatments for difficult symptoms such as delirium, dyspnea, and pain before the symptom was determined as refractory was included; (4) the principle of proportionality was newly defined from an ethical point of view; and (5) families' consent was regarded as being desirable (mandatory in the previous version). Conclusions: We described the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Further consensus building is necessary.
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Affiliation(s)
- Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Mika Baba
- Department of Palliative Medicine, Suita Tokushukai Hospital, Suita, Japan
| | | | - Hiroko Sumi
- Nursing Department, Kyoto University Hospital, Kyoto, Japan
| | - Shimon Tashiro
- Department of Sociology, Graduate School of Arts and Letters, Tohoku University, Sendai, Japan
| | - Kaoruko Aita
- Uehiro Division, The Center for Death and Life Studies and Practical Ethics, Graduate School of Humanities and Sociology, The University of Tokyo, Tokyo, Japan
| | - Tetsuro Shimizu
- Iwate University of Health and Medical Sciences, Morioka, Japan
| | - Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Go Sekimoto
- Home Palliative Care, Sekimoto Home Care Clinic, Kobe, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Toyonaka, Japan
| | | | - Jun Nagayama
- Division of Palliative Medicine, Hamanomachi Hospital, Fukuoka, Japan
| | - Eriko Hayashi
- Department of Nursing, Fujisawa Shounandai Hospital, Kanagawa, Japan
| | - Yukie Hisayama
- Patient Family Support Center, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Hirofumi Abo
- Department of Palliative Medicine, Rokko Hospital, Kobe, Japan
| | | | - Masayuki Ikenaga
- Department of Palliative Medicine, Yodogawa Christian Hospital, Osaka, Japan
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20
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Vivat B, Bemand-Qureshi L, Harrington J, Davis S, Stone P. Palliative care specialists in hospice and hospital/community teams predominantly use low doses of sedative medication at the end of life for patient comfort rather than sedation: Findings from focus groups and patient records for I-CAN-CARE. Palliat Med 2019; 33:578-588. [PMID: 30747052 PMCID: PMC6537030 DOI: 10.1177/0269216319826007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Little research has explored the detail of practice when using sedative medications at the end of life. One work package of the I-CAN-CARE research programme investigates this in UK palliative care. AIMS To investigate current practices when using sedative medication at the end of life in London, UK, by (1) qualitatively exploring the understandings of palliative care clinicians, (2) examining documented sedative use in patient records and (3) comparing findings from both investigations. DESIGN We conducted focus groups with experienced palliative care physicians and nurses, and simultaneously reviewed deceased patient records. SETTING/PARTICIPANTS In total, 10 physicians and 17 senior nurses in London hospice or hospital/community palliative care took part in eight focus groups. Simultaneously, 50 patient records for people who received continuous sedation at end of life in the hospice and hospital were retrieved and reviewed. RESULTS Focus group participants all said that they used sedative medication chiefly for managing agitation or distress; selecting drugs and dosages as appropriate for patients' individual needs; and aiming to use the lowest possible dosages for patients to be 'comfortable', 'calm' or 'relaxed'. None used structured observational tools to assess sedative effects, strongly preferring clinical observation and judgement. The patient records' review corroborated these qualitative findings, with the median continuous dose of midazolam administered being 10 mg/24 h (range: 0.4-69.5 mg/24 h). CONCLUSION Clinical practice in these London settings broadly aligns with the European Association for Palliative Care framework for using sedation at the end of life, but lacks any objective monitoring of depth of sedation. Our follow-on study explores the utility and feasibility of objectively monitoring sedation in practice.
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Affiliation(s)
- Bella Vivat
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | | | - Jane Harrington
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, UCL, London, UK
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21
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Kim YS, Song HN, Ahn JS, Koh SJ, Ji JH, Hwang IG, Yun J, Kwon JH, Kang JH. Sedation for terminally ill cancer patients: A multicenter retrospective cohort study in South Korea. Medicine (Baltimore) 2019; 98:e14278. [PMID: 30702591 PMCID: PMC6380862 DOI: 10.1097/md.0000000000014278] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sedation therapy is a potential solution to providing relief from refractory symptoms at end of life. The aim of this study was to investigate actual sedation practice and physician characteristics associated with the use of sedation for terminally ill cancer patients in South Korea.A retrospective review was conducted on consecutive patients who had died from cancer at seven tertiary medical centers between January 2010 and October 2015. The use of sedation was defined as the administration of sedative agents to relieve intolerable symptoms within the last 2 weeks preceding death. Patients and physician characteristics and information on the use of sedation were collected.A total of 8309 patients were included in the study. Sedatives were administered in 1334 patients (16.1%) for the following indications: delirium in 39.3%, intractable pain in 23.1%, and dyspnea in 21.9%. Median duration of sedation from initiation to death was 3 days. The use of sedation depended on physician specialty and experience. Family physicians used sedation most often (57.6%), followed by medical oncologists (13.9%), other internists (10.7%), and surgical oncologists (9.4%). The use of sedation was highest for physicians with >5 to 10 years practice experience (22.1%) and lowest for those in practice for 5 years or less (10.2%). The proportion of patients receiving sedation also varied markedly across participating institutions (range, 7.0%-49.7%).This large cohort study provides insight into sedation practice for terminally ill cancer patients in South Korea. Our study shows that the use of sedation depends on physician background and institution. A nation-wide guidelines and continued education on end-of-life sedation are required in South Korea.
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Affiliation(s)
- Young Saing Kim
- Division of Medical Oncology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon
| | - Haa-Na Song
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Jun Ho Ji
- Division of Hematology-Oncology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon
| | - In Gyu Hwang
- Division of Hematology/Oncology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul
| | - Jina Yun
- Division of Hematology-Oncology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon
| | - Jung Hye Kwon
- Division of Hemato-oncology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul
| | - Jung Hun Kang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju
- Institute of Health Science, College of Medicine, Gyeongsang National University, Jinju, South Korea
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Abstract
'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.
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Nishioka M, Okuyama T, Uchida M, Aiki S, Ito Y, Osaga S, Imai F, Akechi T. What is the appropriate communication style for family members confronting difficult surrogate decision-making in palliative care?: A randomized video vignette study in medical staff with working experiences of clinical oncology. Jpn J Clin Oncol 2019; 49:48-56. [PMID: 30508206 DOI: 10.1093/jjco/hyy178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background The family members of terminally ill patients are often requested to make difficult surrogate decisions during palliative care. This study sought to clarify the appropriate communication style for physicians as perceived by family members confronting difficult surrogate decision-making. Methods This experimental psychological study used scripted videos. In the videos, the physician described treatment options including continuous deep sedation to the family members of patients with cancer and terminal delirium using an autonomous or paternalistic style. Medical professionals with clinical experience in oncology were randomly assigned to either group viewing the videos. The primary outcomes were physician compassion, decisional conflict and emotion scores. We also evaluated the communication style preference. Results In total, 251 participants completed this study. Although participants in both groups reported high physician compassion, participants in the autonomous style group reported lower compassion scores (reflecting higher physician compassion) (mean 15.0 vs. 17.3, P = 0.050), lower decisional conflicts scores (51.1 vs. 56.8, P = 0.002) and comparable emotions compared with those in the paternalistic style group. Seventy-six percent of participants preferred the autonomous style. Conclusions Regarding difficult surrogate decision-making, the autonomous style might be more appropriate than the paternalistic style. However, various factors, such as family members' communication style preferences, family members' values, physician-family relationships and ethnic cultures, should be considered.
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Affiliation(s)
- Masahiro Nishioka
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Toru Okuyama
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Sayo Aiki
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Department of Palliative Care, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan.,Department of Palliative Medicine, Higashi-Osaka Hospital, Chuo, Joto-ku, Osaka, Japan
| | - Yoshinori Ito
- Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Satoshi Osaga
- Clinical Research Management Center, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Fuminobu Imai
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.,Division of Psycho-oncology and Palliative Care, Nagoya City University Hospital, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan
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Maeda S, Morita T, Ikenaga M, Abo H, Kizawa Y, Tsuneto S. Changes in opinions on palliative sedation of palliative care specialists over 16 years and their effects on clinical practice. Support Care Cancer 2018; 27:2211-2219. [DOI: 10.1007/s00520-018-4497-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/03/2018] [Indexed: 11/30/2022]
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Abstract
Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.
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Affiliation(s)
| | | | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy.
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Benítez-Rosario MA, Morita T. Palliative sedation in clinical scenarios: results of a modified Delphi study. Support Care Cancer 2018; 27:1647-1654. [PMID: 30094733 DOI: 10.1007/s00520-018-4409-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
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Schildmann E, Pörnbacher S, Kalies H, Bausewein C. 'Palliative sedation'? A retrospective cohort study on the use and labelling of continuously administered sedatives on a palliative care unit. Palliat Med 2018; 32:1189-1197. [PMID: 29557260 DOI: 10.1177/0269216318764095] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sedatives are frequently used towards the end of life. However, there is scarce information when their use is labelled as 'palliative sedation'. AIM To assess the use and labelling of 'continuous administration of sedatives within the last 7 days of life', based on objective operational criteria, on a palliative care unit. DESIGN Retrospective cohort study, using medical records. Explorative statistical analysis (SPSS 23). SETTING/PARTICIPANTS Patients who died on a palliative care unit from August 2014 to July 2015. Sedatives recorded were benzodiazepines, levomepromazine, haloperidol ⩾5 mg/day and propofol. RESULTS Of the 192 patients, 149 (78%) patients received continuous sedatives within the last week of life. The prevalence of delirium/agitation was significantly higher in patients with continuous sedatives compared to those without continuous sedatives at admission to the unit (35% vs 16%, p = 0.02) and on the day before death (58% vs 40%, p = 0.04). The term '(palliative) sedation' was used in the records for 22 of 149 (15%) patients with continuous sedatives. These patients had significantly higher total daily midazolam doses 2 days before death (median (range), 15.0 (6.0-185.0) mg vs 11.5 (1.0-70.0) mg, p = 0.04) and on the day of death (median (range), 19.5 (7.5-240.0) mg vs 12.5 (2.0-65.0) mg, p = 0.01). The dose range was large in both groups. CONCLUSION The prevalence of delirium/agitation was associated with the administration of continuous sedatives. There was no consistent pattern regarding labelling the use of continuous sedatives as '(palliative) sedation'. Multicentre mixed-methods research is needed for a better characterization of sedation practices in palliative care.
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Affiliation(s)
- Eva Schildmann
- Department of Palliative Medicine, University Hospital Munich, LMU Munich, Munich, Germany
| | - Sebastian Pörnbacher
- Department of Palliative Medicine, University Hospital Munich, LMU Munich, Munich, Germany
| | - Helen Kalies
- Department of Palliative Medicine, University Hospital Munich, LMU Munich, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital Munich, LMU Munich, Munich, Germany
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Caraceni A, Speranza R, Spoldi E, Ambroset CS, Canestrari S, Marinari M, Marzi AM, Orsi L, Piva L, Rocchi M, Valenti D, Zeppetella G, Zucco F, Raimondi A, Matos LV, Brunelli C. Palliative Sedation in Terminal Cancer Patients Admitted to Hospice or Home Care Programs: Does the Setting Matter? Results From a National Multicenter Observational Study. J Pain Symptom Manage 2018; 56:33-43. [PMID: 29548893 DOI: 10.1016/j.jpainsymman.2018.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 11/20/2022]
Abstract
CONTEXT Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking. OBJECTIVES Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process, and clinical aspects of PS. METHODS About 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness were registered every eight hours to death. RESULTS About 4276 patients were screened, 2894 followed till death, and 531 (18%) underwent PS. PS rate was 15% in HC and 21% in HS (P < 0.001). Principal refractory symptoms were delirium (54%) and dyspnea (45%), respectively, more common in HC (P < 0.001) and HS (P = 0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug (94% HS vs. 75% HC; P < 0.001) mainly by continuous infusion (74% HC vs. 89% HS; P < 0.001). PS duration was less than 48 hours in 67% of patients. Hydration during PS was less frequent in HC (27% vs. 49%; P < 0.001). In the eight hours before death, consciousness level was unrousable to mild physical stimulation in 81% and symptom control complete in 89% of cases. CONCLUSION Our results show feasibility of PS in HC and HS and suggest setting differences in rates, indications, and practice of PS, possibly related to patients' selection or care organization.
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Affiliation(s)
- Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Elio Spoldi
- Hospice and Palliative Care Unit, AO Cremona Hospital, Cremona, Italy; Associazione Cremonese contro il dolore (ACCD), Cremona, Italy
| | | | - Stefano Canestrari
- Department of Legal Studies, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | | | - Luciano Orsi
- Palliative Care Unit, AO Ospedale Maggiore Crema, Crema, Italy
| | - Laura Piva
- Palliative Care Unit, AO San Paolo Hospital, Milan, Italy
| | - Mirta Rocchi
- Hospice "Casa Madonna dell'Uliveto", Albinea (RE), Italy
| | | | | | - Furio Zucco
- Hospice and Palliative Care Unit, AO G. Salvini, Garbagnate Milanese (MI), Italy
| | - Alessandra Raimondi
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Department of Cancer Research and Molecular Medicine, European Palliative Care Research Center (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Klein C, Wittmann C, Wendt KN, Ostgathe C, Stiel S. [Palliative sedation : Development and consensus of a German language documentation template]. Anaesthesist 2018; 67:504-511. [PMID: 29767825 DOI: 10.1007/s00101-018-0451-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Palliative sedation (PS) serves as a therapeutic option in cases of otherwise intractable suffering. As the use of sedative and hypnotic medication in many diverse situations is a core competency of anesthesiology, anesthesiologists are confronted with questions of sedative therapy at the end of life in institutions for specialized palliative care, in intensive care units and intermediate care wards. In recent years a number of guidelines have been published internationally but so far no official guidelines exist in Germany. The most recognized document is the European Association for Palliative Care (EAPC) framework on PS. This project aims to develop a German language template for the preparation, application, documentation and evaluation of PS according to the current frameworks, especially the EAPC framework on PS. METHODS A first draft of the template was generated by the project team using the EAPC framework and individual templates of various institutions, which had been collected during a previous project. Professionals (n = 136) from inpatient and outpatient specialist palliative and hospice care were invited to assess all items of the draft regarding "relevance", "wording" and "feasibility" in an online Delphi survey (Unipark®, Questback, Cologne, Germany). After the second Delphi round an expert panel was asked to reflect the results and generate a final draft. Approval was granted if acceptance exceeded 75% of participants. RESULTS The 3 rounds of the Delphi process were completed by 64, 46 and 41 participants, respectively. The Delphi process as well as the expert panel led to significant changes of the template. The indications for PS had to be clarified. The significance of documentation of vital parameters, such as oxygen saturation, blood pressure or respiratory rate during PS was intensively discussed. In many teams, predominantly hospice or outpatient palliative care teams, it seems to be difficult to measure these parameters or it is regarded as inappropriate in a palliative care setting. In contrast, the EAPC framework recommends monitoring of vital parameters in cases of intermittent or respite sedation. Finally, a solution was found to support documentation of additional data without the explicit mentioning of specific parameters. After the third Delphi round, all 16 items of the documentation template reached consensus with respect to relevance (82.9-100%), clarity of wording (80.5-100%), and feasibility in practice (78-100%). CONCLUSION This article provides an empirically based, multiprofessional consented documentation template for PS. Core elements of the documentation of PS are the indications and the decision process towards PS. During the treatment, at least the level of sedation and the symptom burden have to be recorded. The documentation of vital signs during PS remains a highly disputed topic. The presented data suggest that especially in outpatient settings and in hospices measuring and documentation of vital parameters is uncommon and therefore is often regarded as not feasible. This template can help to support the medically and ethically sound use of PS and facilitate research. The template can be accessed at http://www.palliativmedizin.uk-erlangen.de/forschung/downloads/ .
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Affiliation(s)
- C Klein
- Palliativmedizinische Abteilung in der Anästhesiologischen Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland.
| | - C Wittmann
- Palliativmedizinische Abteilung in der Anästhesiologischen Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - K N Wendt
- Palliativmedizinische Abteilung in der Anästhesiologischen Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - C Ostgathe
- Palliativmedizinische Abteilung in der Anästhesiologischen Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - S Stiel
- Institut für Allgemeinmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
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Hamano J, Morita T, Ikenaga M, Abo H, Kizawa Y, Tunetou S. A Nationwide Survey About Palliative Sedation Involving Japanese Palliative Care Specialists: Intentions and Key Factors Used to Determine Sedation as Proportionally Appropriate. J Pain Symptom Manage 2018; 55:785-791. [PMID: 29056564 DOI: 10.1016/j.jpainsymman.2017.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Although there has long been debate about physicians' intentions and what physicians consider to be proportionally appropriate when performing palliative sedation, few large studies have been performed. OBJECTIVES To identify physicians' intentions when starting continuous deep sedation and to clarify what factors determine whether physicians regard sedation as proportionally appropriate in relation to expected survival, the patients' wishes, and refractoriness. METHODS A nationwide questionnaire survey of Japanese palliative care specialists was performed from August to December 2016. We defined continuous deep sedation as the continuous use of sedatives to relieve intolerable and refractory symptoms with the loss of consciousness until death. RESULTS Of the 695 palliative care specialists enrolled, 440 were analyzed (response rate, 69%). A total of 95% and 87% of the physicians reported that they explicitly intended to perform symptom palliation and decrease consciousness levels, respectively. Moreover, 38% answered that they explicitly intended to maintain unconsciousness until death, and 11% reported that they intended to shorten survival to some extent. The respondents considered that continuous deep sedation is more appropriate when the predicted survival is shorter, the patients' wishes are consistent and clear, and confidence in the refractoriness of symptoms is higher. CONCLUSIONS Japanese palliative care specialists explicitly intend to control symptoms and reduce the level of consciousness when performing continuous deep sedation, but there are differences in their intentions with regard to maintaining unconsciousness until death. Predicted survival, patients' wishes, and confidence in refractoriness are associated with physicians' judgment that sedation is proportionally appropriate.
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Affiliation(s)
- Jun Hamano
- Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Tatsuya Morita
- Palliative Care Team, Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Kita-ku, Hamamatsu, Shizuoka, Japan
| | - Masayuki Ikenaga
- Hospice Children's Hospice Hospital, Yodogawa Christian Hospital, Osaka, Japan
| | - Hirofumi Abo
- Department of Palliative Medicine, Rokko Hospital, Kobe, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Satoru Tunetou
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Imai K, Morita T, Yokomichi N, Mori M, Naito AS, Tsukuura H, Yamauchi T, Kawaguchi T, Fukuta K, Inoue S. Efficacy of two types of palliative sedation therapy defined using intervention protocols: proportional vs. deep sedation. Support Care Cancer 2017; 26:1763-1771. [PMID: 29243169 DOI: 10.1007/s00520-017-4011-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/05/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE This study investigated the effect of two types of palliative sedation defined using intervention protocols: proportional and deep sedation. METHODS We retrospectively analyzed prospectively recorded data of consecutive cancer patients who received the continuous infusion of midazolam in a palliative care unit. Attending physicians chose the sedation protocol based on each patient's wish, symptom severity, prognosis, and refractoriness of suffering. The primary endpoint was a treatment goal achievement at 4 h: in proportional sedation, the achievement of symptom relief (Support Team Assessment Schedule (STAS) ≤ 1) and absence of agitation (modified Richmond Agitation-Sedation Scale (RASS) ≤ 0) and in deep sedation, the achievement of deep sedation (RASS ≤ - 4). Secondary endpoints included mean scores of STAS and RASS, deep sedation as a result, and adverse events. RESULTS Among 398 patients who died during the period, 32 received proportional and 18 received deep sedation. The treatment goal achievement rate was 68.8% (22/32, 95% confidence interval 52.7-84.9) in the proportional sedation group vs. 83.3% (15/18, 66.1-100) in the deep sedation group. STAS decreased from 3.8 to 0.8 with proportional sedation at 4 h vs. 3.7 to 0.3 with deep sedation; RASS decreased from + 1.2 to - 1.7 vs. + 1.4 to - 3.7, respectively. Deep sedation was needed as a result in 31.3% (10/32) of the proportional sedation group. No fatal events that were considered as probably or definitely related to the intervention occurred. CONCLUSION The two types of intervention protocol well reflected the treatment intention and expected outcomes. Further, large-scale cohort studies are promising.
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Affiliation(s)
- Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan.
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Akemi Shirado Naito
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Hiroaki Tsukuura
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Toshihiro Yamauchi
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Kaori Fukuta
- Department of Nursing, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Satoshi Inoue
- Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
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Ahn HY, Park SJ, Ahn HK, Hwang IC. An optimal design for the study of palliative sedation-making somewhat better pictures. Support Care Cancer 2017; 26:3-5. [PMID: 28993923 DOI: 10.1007/s00520-017-3925-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/02/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Republic of Korea
| | - So Jung Park
- Department of Hospice and Palliative Care Service, National Cancer Center, Goyang, Republic of Korea
| | - Hee Kyung Ahn
- Department of Medical Oncology, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - In Cheol Hwang
- Department of Family Medicine, Gachon University Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Republic of Korea.
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Rady MY, Verheijde JL. Empirical Clinical Research in Continuous Deep Sedation at the End of Life. J Pain Symptom Manage 2017; 53:e10-e12. [PMID: 28193501 DOI: 10.1016/j.jpainsymman.2017.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/24/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA.
| | - Joseph L Verheijde
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Scottsdale, Arizona, USA
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Morita T, Rietjens JA, Imai K, Mori M, Tsuneto S. Authors' Reply to Twycross. J Pain Symptom Manage 2017; 53:e15-e16. [PMID: 28433545 DOI: 10.1016/j.jpainsymman.2017.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | - Judith A Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Palliative Care Center, Kyoto University Hospital, Kyoto, Japan
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Morita T, Rietjens JA, Imai K, Mori M, Tsuneto S. Authors' Reply to Rady and Verheijde. J Pain Symptom Manage 2017; 53:e12-e13. [PMID: 28414039 DOI: 10.1016/j.jpainsymman.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 11/23/2022]
Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | - Judith A Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Palliative Care Center, Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Kyoto, Japan
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