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Lucena A, Yuguero O. Systematic Review of Common Refractory Symptoms in the End-Of-Life Situation and Its Relation With Euthanasia. OMEGA-JOURNAL OF DEATH AND DYING 2024; 89:1113-1127. [PMID: 35441562 DOI: 10.1177/00302228221089123] [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: 11/17/2022]
Abstract
AIM To analyse the available evidence regarding refractory symptoms to treatment in patients receiving palliative/terminal healthcare. DESIGN A systematic review of various databases between September and December 2020; Pubmed; Cochrane; Scopus and ScienceDirect. Study eligibility criteria: Studies published between 1st January 2015 and 31st of March 2020, in Spanish, English or Catalan conducted in elderly people or terminal patients. The study included systematic reviews, clinical trials and interventions. RESULTS The search returned 782 articles, of which 22 articles were finally reviewed. Of the selected articles, 16 were systematic reviews and three were clinical trials. Three refractory symptoms are notable; breathlessness, delirium and existential suffering. There are various therapeutic approaches for the first two symptoms, but palliative sedation seems to be most effective for existential suffering. CONCLUSIONS Although palliative care enables controlling these symptoms effectively, and following a multidisciplinary approach, there remains a group of patients for whom euthanasia could save foreseeable suffering that is difficult to manage.
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Affiliation(s)
- Alba Lucena
- Surgery Department, Faculty of Medicine, University of Lleida, Lleida, Spain
| | - Oriol Yuguero
- Surgery Department, Faculty of Medicine, University of Lleida, Lleida, Spain
- Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Lleida, Spain
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Thomas C, Kulikowksi JD, Breitbart W, Alici Y, Bruera E, Blackler L, Sulmasy DP. Existential suffering as an indication for palliative sedation: Identifying and addressing challenges. Palliat Support Care 2024:1-4. [PMID: 38419195 PMCID: PMC11358359 DOI: 10.1017/s1478951524000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Julia D. Kulikowksi
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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Beauverd M, Mazzoli M, Pralong J, Tomczyk M, Eychmüller S, Gaertner J. Palliative sedation - revised recommendations. Swiss Med Wkly 2024; 154:3590. [PMID: 38579308 DOI: 10.57187/s.3590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.
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Affiliation(s)
- Michel Beauverd
- Service de soins palliatifs et de support, Département de médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Martyna Tomczyk
- Institute of Humanities in Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Steffen Eychmüller
- Universitäres Zentrum für Palliative Care (UZP), Inselspital, University Hospital, Bern, Switzerland
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
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Rodrigues P, Ostyn J, Mroz S, Ronse A, Menten J, Gastmans C. Palliative care physicians' decision-making about palliative sedation for existential suffering: A Belgian nationwide qualitative study. Palliat Support Care 2024; 22:119-127. [PMID: 36503696 DOI: 10.1017/s1478951522001559] [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: 12/14/2022]
Abstract
OBJECTIVES This study aims to provide an in-depth understanding of the content and process of decision-making about palliative sedation for existential suffering (PS-ES) as perceived by Belgian palliative care physicians. METHODS This Belgian nationwide qualitative study follows a grounded theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 19 Belgian hospital-based palliative care units and 4 stand-alone hospices. We analyzed the data using the Qualitative Analysis Guide of Leuven, and we followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). RESULTS Analysis of the data identified several criteria that physicians apply in their decision-making about PS-ES, namely, the importance of the patient's demand, PS-ES as a last resort option after all alternatives have been applied, the condition of unbearable suffering combined with other kinds of suffering, and the condition of being in a terminal stage. Regarding the process of decision-making itself, physicians refer to the need for multidisciplinary perspectives supported by an interpretative dialogue with the patient and all other stakeholders. The decision-making process involves a specific temporality and physicians' inner conviction about the need of PS-ES. SIGNIFICANCE OF RESULTS Belgian palliative care physicians are not sure about the criteria regarding decision-making in PS-ES. To deal with complex existential suffering in end-of-life situations, they stress the importance of participation by all stakeholders (patient, relatives, palliative care team, other physicians, nurses, social workers, physiotherapists, occupational therapists, chaplains, etc.) in the decision-making process to prevent inadequate decisions being made.
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Affiliation(s)
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Sarah Mroz
- End-of-Life Care Research Group, Free University of Brussels (VUB), Brussels, Belgium
| | - Axelle Ronse
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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Frasca M, Jonveaux T, Lhuaire Q, Bidegain-Sabas A, Chanteclair A, Francis-Oliviero F, Burucoa B. Sedation practices in palliative care services across France: a nationwide point-prevalence analysis. BMJ Support Palliat Care 2024; 13:e1326-e1334. [PMID: 37463761 PMCID: PMC10850836 DOI: 10.1136/spcare-2023-004261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/30/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service. METHODS We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study. RESULTS In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type. CONCLUSIONS This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices.
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Affiliation(s)
- Matthieu Frasca
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Thérèse Jonveaux
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Quentin Lhuaire
- Unité Méthodes d'Evaluation en Santé (UMES), University Hospital of Bordeaux, Bordeaux, France
| | - Adèle Bidegain-Sabas
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Alex Chanteclair
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | | | - Benoît Burucoa
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
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6
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Tomczyk M, Jaques C, Jox RJ. Palliative sedation: ethics in clinical practice guidelines - systematic review. BMJ Support Palliat Care 2024; 13:e651-e663. [PMID: 37567756 DOI: 10.1136/spcare-2023-004266] [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] [Received: 03/10/2023] [Accepted: 07/11/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVES The objective of our study was to determine whether, and to what degree, the ethical dimension was present in clinical practice guidelines (CPGs) on palliative sedation, and to identify the ethical issues with respect to the different forms of this practice. The purpose was purely to be descriptive; our aim was not to make any kind of normative judgements on these ethical issues or to develop our own ethical recommendations. METHODS We performed a systematic review of CPGs on the palliative sedation of adults, focusing our analysis on the ethical dimension of these texts and the ethical issues of this practice. The study protocol is registered on PROSPERO. RESULTS In total, 36 current CPGs from four continents (and 14 countries) were included in our analysis. Generally, ethics was rarely referred to or absent from the CPGs. Only six texts contained a specific section explicitly related to ethics. Ethical issues were named, conceptualised and presented in heterogeneous, often confusing ways. It was impossible to identify the ethical issues of each form of palliative sedation. Ethics expertise was not involved in the development of most of the CPGs and, if it was, this did not always correlate with the ethical dimension of the document. CONCLUSIONS Effective cooperation between palliative care clinicians and ethicists should be encouraged, in order to integrate in particular the crucial ethical issues of continuous deep sedation until death when developing or updating CPGs on palliative sedation.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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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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Garcia Hernandez JS, Aguilar Najera ME, de Hoyos Bermea A, Serrano Zamago AB, Moncivais AS, Morales Pogoda II, Reyes EC, Garcia Araiza MG, Rios EV. Parenteral nutrition in cancer patients outside of oncologic treatment: Bioethical perspective. Clin Nutr ESPEN 2023; 57:138-143. [PMID: 37739648 DOI: 10.1016/j.clnesp.2023.06.036] [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] [Received: 06/08/2023] [Accepted: 06/28/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS The medical care of a patient with an end-stage disease focus on the pursuit of the patient's quality of life. Many treatments can be used to achieve this goal. In this study, the benefits, and burdens of providing parenteral nutrition to patients diagnosed with end-stage cancer were reviewed and analyzed from a bioethical perspective with the aim of issuing a useful recommendation for decision making. METHODOLOGY A qualitative convergent study through interviews and a multiple case study was performed. The study is on the decisions to provide parenteral nutrition as an end-of-life treatment for terminal cancer patients treated in Mexico City. Eight physicians specialized in Oncology and Palliative Care were interviewed and 10 clinical records of patients diagnosed with terminal cancer, who were out of oncologic treatment, who received palliative care and were prescribed parenteral nutrition at the end of life were analyzed. RESULTS The physicians considered parenteral nutrition as an advanced life-sustaining medical treatment and, therefore, susceptible to not being initiated or being withdrawn, according to the patient's clinical situation. Minor complications secondary to parenteral nutrition were found in all the records reviewed, all these patients died in hospital instead of at home. CONCLUSION When death is certain in the short term and cannot be avoided, the role of feeding and nutrition becomes questionable, especially in cancer patients at the end of life, where parenteral nutrition causes more burden than benefit.
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Affiliation(s)
| | | | | | | | - Anahi Sanchez Moncivais
- Escuela Militar de Graduados de Sanidad (Secretaría de la Defensa Nacional-SEDENA), Mexico City, Mexico
| | | | - Eira Cerda Reyes
- Hospital Central Militar (Secretaría de la Defensa Nacional-SEDENA), Mexico City, Mexico
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Lucchi E, Milder M, Dardenne A, Bouleuc C. Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology. BMC Palliat Care 2023; 22:97. [PMID: 37468913 DOI: 10.1186/s12904-023-01219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 07/03/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception. METHODS Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter. RESULTS 63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life. CONCLUSION Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.
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Affiliation(s)
- E Lucchi
- Department of Supportive and Palliative Care, Institut Curie, Saint-Cloud, France.
| | - M Milder
- Department of Clinical Research, Institut Curie, Paris, France
| | - A Dardenne
- Department of Supportive and Palliative Care, Institut Curie, Saint-Cloud, France
| | - C Bouleuc
- Department of Supportive and Palliative Care, Institut Curie, Paris, France
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Di Risio M, Thompson A. Current practices in managing end-of-life existential suffering. Curr Opin Support Palliat Care 2023; 17:119-124. [PMID: 37039587 DOI: 10.1097/spc.0000000000000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Within the context of palliative care, existential suffering (ES) can be an exclusive source of suffering or intertwined with physical pain and/or psychological and spiritual suffering. With newly emerging modalities for addressing this phenomenon and its increasing salience given that many patients cite ES as a significant contributing factor to requests for hastened death, a review of recent interventions for addressing ES at the end of life is timely. RECENT FINDINGS This review of newer approaches to dealing with ES in the palliative context suggests some promising new modalities and pharmacological interventions, such as brain stimulation and the use of psychedelics. The use of other pharmacological interventions, such as palliative sedation and lethal injections, solely for the alleviation of existential distress remains ethically controversial and difficult to disentangle from other forms of suffering, not least because a clear clinical definition of ES has yet to emerge in the literature. SUMMARY The evaluation of end-of-life (EOL) ES mitigating tools should also consider how broader contexts, such as institutional arrangements and barriers, and cultural factors may influence the optimal management of dying persons' ES in the palliative care setting.
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Affiliation(s)
- Michelle Di Risio
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Serey A, Tricou C, Phan-Hoang N, Legenne M, Perceau-Chambard É, Filbet M. Deep continuous patient-requested sedation until death: a multicentric study. BMJ Support Palliat Care 2023; 13:70-76. [PMID: 31005881 DOI: 10.1136/bmjspcare-2018-001712] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/18/2019] [Accepted: 02/27/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES In 2016, a new law was adopted in France granting patients the right, under specific conditions, to continuous deep sedation until death (CDSUD). The goal of this study was to measure the frequency of requests for CDSUD from patients in palliative care. METHODS The data collected from the medical records of patients in palliative care units (PCU) or followed by palliative care support teams (PCST) in the Rhône-Alpes area, who died after CDSUD, focused on the patient's characteristics, the drugs used (and compliance with regulatory processes). RESULTS All 12 PCU and 12 of the 24 PCST were included. Among the 8500 patients followed, 42 (0.5%) requested CDSUD until death. The patients were: 65.7 (SD=13.7) years old, highly educated (69%), had cancer (81%), refractory symptoms (98%) and mostly psychoexistential distress (69%). The request was rejected for 2 (5%) patients and delayed for 31 (74%) patients. After a delay of a mean 8 days, 13 (31%) patients were granted CDSUD. The drug used was midazolam at 115 mg/24 hours (15-480), during a mean of 3 days. PCUs used lower dosages than PCSTs (83 vs 147), with significantly lower initial doses (39 mg vs 132 mg, p=0.01). A life-threatening condition was recorded in 13 cases (31%) and a collegial decision was taken in 25 cases (60%). CONCLUSION This study highlights the low rate of request and the even lower rate of CDSUD in specialised palliative care. However, the sedation for psychoexistential distress and the lack of procedure records raise ethical questions.
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Affiliation(s)
- Adrien Serey
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | - Colombe Tricou
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | | | - Myriam Legenne
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | | | - Marilene Filbet
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
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Elst S, Launois AC, Lecocq D. Pratiques et enjeux de la sédation palliative en Belgique. LA REVUE DE L'INFIRMIÈRE 2023; 72:32-35. [PMID: 37024193 DOI: 10.1016/j.revinf.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
In Belgium, continuous sedation in palliative care is considered a symptomatic treatment. There is no specific legislation to govern it. Its proper use is based on a set of recommendations that ensure both effective treatment and respect for the patient's preferences, within a rigorous ethical framework.
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13
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Gaignard ME, Pautex S, Hurst S. Existential suffering as a motive for assisted suicide: Difficulties, acceptability, management and roles from the perspectives of Swiss professionals. PLoS One 2023; 18:e0284698. [PMID: 37083894 PMCID: PMC10121014 DOI: 10.1371/journal.pone.0284698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/05/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Existential suffering is often a part of the requests for assisted suicide (AS). Its definitions have gained in clarity recently and refer to a distress arising from an inner realization that life has lost its meaning. There is however a lack of consensus on how to manage existential suffering, especially in a country where AS is legal and little is known about the difficulties faced by professionals confronted with these situations. OBJECTIVES To explore the perspectives of Swiss professionals involved in end-of-life care and AS on the management of existential suffering when it is part of AS requests, taking into account the question of roles, as well as on the difficulties they encounter along the way and their views on the acceptability of existential suffering as a motive for AS. METHODS A qualitative study based on face-to-face interviews was performed among twenty-five participants from the fields of palliative and primary care as well as from EXIT right-to-die organization. A semi-structured interview guide exploring four themes was used. Elements from the grounded theory approach were applied. RESULTS Almost all participants reported experiencing difficulties when facing existential suffering. Opinions regarding the acceptability of existential suffering in accessing AS were divided. Concerning its management, participants referred to the notion of being present, showing respect, seeking to understand the causes of suffering, helping give meaning, working together, psychological support, spiritual support, relieving physical symptoms and palliative sedation. CONCLUSION This study offers a unique opportunity to reflect on what are desirable responses to existential suffering when it is part of AS requests. Existential suffering is plural and implies a multiplicity of responses as well. These situations remain however difficult and controversial according to Swiss professionals. Clinicians' education should further address these issues and give professionals the tools to better take care of these people.
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Affiliation(s)
- Marie-Estelle Gaignard
- Institute for Ethics, History and the Humanities, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Sophie Pautex
- Division of Palliative Medicine Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| | - Samia Hurst
- Institute for Ethics, History and the Humanities, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Warton C, McDougall RJ. Fertility preservation for transgender children and young people in paediatric healthcare: a systematic review of ethical considerations. JOURNAL OF MEDICAL ETHICS 2022; 48:1076-1082. [PMID: 34980674 PMCID: PMC9726968 DOI: 10.1136/medethics-2021-107702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/03/2021] [Indexed: 05/11/2023]
Abstract
BACKGROUND While fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered for transgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare. METHODS A systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatric transgender healthcare. The text of included publications was analysed inductively, guided by the Qualitative Analysis Guide of Leuven. RESULTS Twenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making. CONCLUSION In the identified literature, there is consensus that transgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child's age, mental health, and parents' views.
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Affiliation(s)
- Chanelle Warton
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosalind J McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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15
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Lee SH, Kwon JH, Won YW, Kang JH. Palliative Sedation in End-of-Life Patients in Eastern Asia: A Narrative Review. Cancer Res Treat 2022; 54:644-650. [PMID: 35436813 PMCID: PMC9296933 DOI: 10.4143/crt.2022.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/17/2022] [Indexed: 11/21/2022] Open
Abstract
Although palliative sedation (PS) is a common practice in the palliative care of cancer patients in Western countries, there is little related research on the practice in Korea. PS can be classified into several categories according to sedation level and continuity. PS is clearly distinct from euthanasia. While euthanasia is illegal and regarded as unethical in Korea, there is little ethical and legal controversy about PS in terms of the doctrine of double effect. Most studies have asserted that PS does not shorten the survival of terminal cancer patients. Since preference for PS heavily depends on stakeholder value, it should be preceded by shared decision-making through full communication among the patient, family members, and medical team. This is a narrative review article analyzing previous studies, especially from the three Eastern Asian countries, Korea, Japan and Taiwan, which share similar cultures compared with Western countries. Practical issues concerning PS-for example, prevalence, type and dosage of medications, salvage medication, timing of its initiation, and assessment-are described in detail.
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Affiliation(s)
- Seung Hun Lee
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Young-Woong Won
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
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16
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Sandra K, Maria H, Larissa P, Joachim P, Jeremias B, Eva S, Christoph O. Possible age-related differences in healthcare professionals' perspectives on younger and older patients' autonomy and decision-making in the context of sedation in specialised palliative care: exploratory secondary qualitative content and linguistic conversation analysis of interviews with healthcare professionals. BMC Palliat Care 2022; 21:71. [PMID: 35550117 PMCID: PMC9101857 DOI: 10.1186/s12904-022-00963-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/26/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic illnesses and multi-morbidity can threaten competence and independence, particularly in old age. Autonomy becomes increasingly important in the context of sedation, as in this case medication leads to (further) changes of consciousness. The study aimed to identify possible age-related differences in the perspectives of healthcare professionals on patients' autonomy, in the context of sedation in specialised palliative care. METHOD Secondary analysis of interviews with healthcare professionals, analysed by qualitative content and linguistic conversation analysis. The interviews analysed span 51 healthcare professionals in specialised palliative care across 17 centres (adult inpatient and specialist palliative home care services) in Germany. RESULTS The study shows that the perspectives of healthcare professionals on patients' autonomy differs according to the age of the patient in the context of sedation in specialised palliative care. The different perspectives may lead to different ways of treating the patients, for example a greater space of autonomy and decision-making for younger patients. CONCLUSION In particular, measures that may restrict consciousness (e.g. sedation) and thus influence patients' ability to fully exercise their autonomy and fully participate in decision-making require special attention by healthcare professionals with respect to possible influences on treatment, such as different perceptions by healthcare professionals based on the patient's age or age-related stereotypes. TRIAL REGISTRATION The study "SedPall" is registered in the German Clinical Trials Register (ID: DRKS00015047 ).
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Affiliation(s)
- Kurkowski Sandra
- Department of Palliative Medicine, CCC Erlangen – EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Berlin, Germany
| | - Heckel Maria
- Department of Palliative Medicine, CCC Erlangen – EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Pfaller Larissa
- Institute of Sociology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Peters Joachim
- Chair of German Linguistics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bazata Jeremias
- Department of Palliative Medicine, University Hospital, LMU, Munich, Germany
| | - Schildmann Eva
- Department of Palliative Medicine, University Hospital, LMU, Munich, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care & Charité Comprehensive Cancer Center, Berlin, Germany
| | - Ostgathe Christoph
- Department of Palliative Medicine, CCC Erlangen – EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Rodrigues P, Ostyn J, Mroz S, Ronsse A, Menten J, Gastmans C. Ethics of sedation for existential suffering: palliative medicine physician perceptions - qualitative study. BMJ Support Palliat Care 2022; 13:209-217. [PMID: 35418444 DOI: 10.1136/bmjspcare-2021-003395] [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: 10/20/2021] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Palliative sedation for existential suffering (PS-ES) is considered a controversial practice to control refractory suffering at the end of life. This study aims to explore Belgian palliative care physicians' perceptions regarding the ethics of PS-ES. METHODS This nationwide qualitative study follows a Grounded Theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 23 Belgian hospitals and hospices (Flanders, Brussels, Wallonia). We analysed the data using the Qualitative Analysis Guide Of Leuven and we followed the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS The data revealed that Belgian palliative care physicians have difficulty characterising ES and distinguishing it from other types of suffering. They express mixed attitudes towards PS-ES and employ a wide range of ethical arguments in favour and against it, which are mainly linked to the four principles of biomedical ethics. CONCLUSION Since there is a lack of consensus among Belgian palliative care physicians about PS-ES, further research is needed to clarify their attitudes. A better understanding of physicians' underlying presuppositions can provide more insight into their perceptions of ES and PS-ES and provide further insight for establishing good practices in ES management at the end of life.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah Mroz
- Vrije Universiteit Brussel, Brussel, Belgium
| | - Axelle Ronsse
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan Menten
- Radiation-Oncology and Palliatiev Care, UZ Gasthuisberg, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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18
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Silva HLM, Valério PHM, Barreira CRA, Peria FM. Personal positioning of oncology patients in palliative care: a mixed-methods study. BMC Palliat Care 2022; 21:34. [PMID: 35277164 PMCID: PMC8917691 DOI: 10.1186/s12904-022-00916-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background Advanced oncological disease requires comprehensive health care, although attention is predominantly paid to the physical dimension of care. The consideration of personal positioning encompasses other dimensions of patients’ management of their illness, such as existential management and expanding forms of care. The objective of this study was to understand the personal positioning of cancer patients in palliative care. Methods This was a cross-sectional study using the mixed convergent parallel method. The sample consisted of 71 cancer patients in palliative care, of whom 14 participated in the qualitative and quantitative portions and 57 participated in only the quantitative portion. Phenomenological interviews were performed, and qualitative and quantitative methods were used to collect meaning of life (PIL-Test), quality of life (EORTC QLQ C-30), anxiety and depression (HADS) and sociodemographic data. The interview results were analysed according to the principles of classical phenomenology, and the quantitative data were analysed using the generalized structural equations model. Results The results showed that the patients turned to living, focusing on their possibilities and distancing themselves from the impact of the illness and the factuality of death, which the patients themselves associated with not succumbing to depression, a condition whose signs were exhibited by 21% of the sample. Sustaining this positioning required a tenacious fight, which feeds on sensitivity to life. Linked to this position was the belief in the continuation of life through religious faith, together with the patients’ realization of the meaning of their lives. In this same direction, there was a direct association between awareness of the meaning of life and increased scores on the functional scales (p < 0.01) and decreased scores for symptoms (p < 0.01), anxiety (p = 0.02) and depression (p < 0.01). The last element that emerged and structured this experience was the intense will to live and a sense of the value of life. Conclusions Through the use of mixed methods, the present study recognized the existential positioning of cancer patients in palliative care. This understanding can aid in the realization of more comprehensive and meaningful treatment plans and can contribute to the goal of achieving humanization in this area of treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00916-5.
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Pesut B, Wright DK, Thorne S, Hall MI, Puurveen G, Storch J, Huggins M. What's suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID). BMC Palliat Care 2021; 20:174. [PMID: 34758799 PMCID: PMC8582137 DOI: 10.1186/s12904-021-00869-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses' perspectives. METHODS A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent. RESULTS Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying. CONCLUSIONS Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices.
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Affiliation(s)
- Barbara Pesut
- School of Nursing, University of British Columbia Okanagan, ARTS 3rd Floor, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada.
| | | | - Sally Thorne
- School of Nursing, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
| | - Margaret I Hall
- Society of Notaries Public of BC, Chair in Applied Legal Studies, School of Criminology, Simon Fraser University, Surrey, BC, V5A 1S6, Canada
| | - Gloria Puurveen
- School of Nursing, University of British Columbia Okanagan, ARTS 3rd Floor, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
| | - Janet Storch
- School of Nursing, University of Victoria, Victoria, BC, V8P 5C2, Canada
| | - Madison Huggins
- School of Nursing, University of British Columbia Okanagan, ARTS 3rd Floor, 1147 Research Road, Kelowna, BC, V1V 1V7, Canada
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20
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Increasing our understanding of nonphysical suffering within palliative care: A scoping review. Palliat Support Care 2021; 20:417-432. [DOI: 10.1017/s1478951521001127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Nonphysical suffering is emotional, psychological, existential, spiritual, and/or social in nature. While palliative care is a discipline dedicated to the prevention and relief of suffering — both physical and nonphysical — little is known about existing research specific to nonphysical suffering within the context of palliative care. This scoping review helps to fill this gap.
Method
Three hundred and twenty-eight unique records were identified through a systematic search of three databases (MEDLINE, CINAHL, and PsycINFO). The following keywords were used: (suffering) AND (palliative OR “end of life” OR “end-of-life” OR hospice OR dying OR terminal* ill*). Thirty studies published between 1998 and 2019 met the inclusion criteria.
Results
Losses, worries, and fears comprise patients’ primary sources of nonphysical suffering. Patients face numerous barriers in expressing their nonphysical suffering to healthcare providers. The idea that patients can choose how they perceive their circumstances, thereby minimizing their nonphysical suffering, is pervasive in the research. The nature of nonphysical suffering experienced by family caregivers and palliative care clinicians is revealed in the review. The unique and sensitive interplay between nonphysical suffering and both palliative sedation and requests for hastened death is also evident. Overall, seven themes can be identified: (i) patients’ experiences of nonphysical suffering; (ii) patient coping mechanisms; (iii) efforts to measure nonphysical suffering; (iv) palliative sedation; (v) requests for hastened death; (vi) family suffering; and (vii) clinician suffering.
Significance of results
This is the first scoping review to map palliative care's research specific to suffering that is social, emotional, spiritual, psychological, and/or existential in nature. Its findings expand our understanding of the nature of nonphysical suffering experienced by patients, families, and palliative care clinicians. The review's findings have significant implications for front-line practice and future research.
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21
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Blake RR, Blake C. Why People Think They Might Hasten Their Death When Faced With Irremediable Health Conditions Compared to Why They Actually Do so. OMEGA-JOURNAL OF DEATH AND DYING 2021:302228211033368. [PMID: 34293978 DOI: 10.1177/00302228211033368] [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: 11/16/2022]
Abstract
This study surveys the differences of relatively healthy proponents of end-of-life choices and people with irremediable health conditions having already made the decision to hasten their deaths on what each group considers important in influencing a desire to hasten death. Psychosocial factors were more important than physical ones for both groups; but those contemplating what might influence them to hasten their deaths in the future thought pain and feeling ill would be much bigger factors than they turned out to be for those deciding to do so. Those having decided to hasten their deaths cited the lack of any further viable medical treatments and having to live in a nursing home as bigger factors. Identifying these psychosocial factors influencing a desire for a hastened death suggests that caregivers and medical providers may want to review what compassionate understanding and support looks like for people wanting to hasten their death.
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Affiliation(s)
- Robert R Blake
- Psychology Private Practice, Indianapolis, Indiana, United States
| | - Charlie Blake
- Biology Department, Webster University, Webster Groves, Missouri, United States
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22
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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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Arantzamendi M, Belar A, Payne S, Rijpstra M, Preston N, Menten J, Van der Elst M, Radbruch L, Hasselaar J, Centeno C. Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review. J Pain Symptom Manage 2021; 61:831-844.e10. [PMID: 32961218 DOI: 10.1016/j.jpainsymman.2020.09.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022]
Abstract
CONTEXT Near the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed. OBJECTIVES To explore clinical aspects of palliative sedation in recent prospective studies. METHODS Systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019), combining sedation, palliative care, and prospective. Article quality was assessed. RESULTS Ten prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%-83%), pain (25%-65%), and dyspnea (16%-59%). In some articles, psychological and existential distress were mentioned (16%-59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication-propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort. CONCLUSION Assessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.
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Affiliation(s)
- Maria Arantzamendi
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain
| | - Alazne Belar
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain.
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Johan Menten
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Van der Elst
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitaetsklinikum Bonn, Bonn, Germany
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Carlos Centeno
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain; Clínica Universidad de Navarra, Departamento Medicina Paliativa, Pamplona, Spain
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24
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Mann SP, Treit PV, Geyer PE, Omenn GS, Mann M. Ethical Principles, Constraints and Opportunities in Clinical Proteomics. Mol Cell Proteomics 2021; 20:100046. [PMID: 33453411 PMCID: PMC7950205 DOI: 10.1016/j.mcpro.2021.100046] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022] Open
Abstract
Recent advances in mass spectrometry (MS)-based proteomics have vastly increased the quality and scope of biological information that can be derived from human samples. These advances have rendered current workflows increasingly applicable in biomedical and clinical contexts. As proteomics is poised to take an important role in the clinic, associated ethical responsibilities increase in tandem with impacts on the health, privacy, and wellbeing of individuals. We conducted and here report a systematic literature review of ethical issues in clinical proteomics. We add our perspectives from a background of bioethics, the results of our accompanying paper extracting individual-sensitive results from patient samples, and the literature addressing similar issues in genomics. The spectrum of potential issues ranges from patient re-identification to incidental findings of clinical significance. The latter can be divided into actionable and unactionable findings. Some of these have the potential to be employed in discriminatory or privacy-infringing ways. However, incidental findings may also have great positive potential. A plasma proteome profile, for instance, could inform on the general health or disease status of an individual regardless of the narrow diagnostic question that prompted it. We suggest that early discussion of ethical issues in clinical proteomics can ensure that eventual healthcare practices and regulations reflect the considered judgment of the community and anticipate opportunities and problems that may arise as the technology matures.
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Affiliation(s)
- Sebastian Porsdam Mann
- Department of Media, Cognition and Communication, University of Copenhagen, Copenhagen, Denmark; Uehiro Center for Practical Ethics, University of Oxford, Oxford, UK; New address: Faculty of Law, University of Oxford, Oxford, UK.
| | - Peter V Treit
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Philipp E Geyer
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany; NNF Center for Protein Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; New address: OmicEra Diagnostics GmbH, Planegg, Germany
| | - Gilbert S Omenn
- Departments of Computational Medicine & Bioinformatics, Internal Medicine, Human Genetics, and School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Matthias Mann
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, Martinsried, Germany; NNF Center for Protein Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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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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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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Piedade MAO, Cardoso Filho CA, Priolli DG. Prevalence of palliative sedation in the State of São Paulo: an emerging medical demand. EINSTEIN-SAO PAULO 2020; 18:eAO5395. [PMID: 32935826 PMCID: PMC7480494 DOI: 10.31744/einstein_journal/2020ao5395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/10/2020] [Indexed: 11/14/2022] Open
Abstract
Objective To investigate the prevalence of palliative sedation use and related factors. Methods An observational study based on data collected via electronic questionnaire comprising 23 close-ended questions and sent to physicians living and working in the state of São Paulo. Demographic data, prevalence and frequency of palliative sedation use, participant’s familiarity with the practice and related motivating factors were analyzed. In order to minimize memory bias, questions addressing use frequency and motivating factors were limited to the last year prior to survey completion date. Descriptive statistics were used to summarize data. Results In total, 20,168 e-mails were sent and 324 valid answers obtained, resulting in 2% adherence. The overall prevalence of palliative sedation use over the course of professional practice was 68%. However, only 48% of respondents reported having used palliative sedation during the last year, primarily to relieve pain (35%). The frequency of use ranged from one to six times (66%) during the study period and the main reason for not using was the lack of eligible patients (64%). Approximately 83% of physicians felt comfortable using palliative sedation but only 26% reported having specific academic training in this field. Conclusion The prevalence of palliative sedation use is high, the primary indication being pain relief. However, frequency of use is low due to lack of eligible patients.
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Gamblin V, Berry V, Tresch-Bruneel E, Reich M, Da Silva A, Villet S, Penel N, Prod'Homme C. Midazolam sedation in palliative medicine: retrospective study in a French center for cancer control. BMC Palliat Care 2020; 19:85. [PMID: 32560644 PMCID: PMC7305615 DOI: 10.1186/s12904-020-00592-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 06/15/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND French legislation about sedation in palliative medicine evolved in 2016 with the introduction of a right to deep and continuous sedation, maintained until death. The objective was to describe midazolam sedation at the COL (Centre Oscar Lambret [Oscar Lambret Center], French regional center for cancer control), in order to establish a current overview before the final legislative changes. METHODS Descriptive, retrospective and single-center study, concerning major patients in palliative care hospitalized from 01/01/2014 to 12/31/2015, who had been sedated by midazolam. The proven sedations (explicitly named) and the probable sedations were distinguished. RESULTS A total of 54 sedations were identified (48 proven, 6 probable). Refractory symptoms accounted for 48.1% of indications, complications with immediate risk of death 46.3%, existential suffering 5.6%. Titration was performed in 44.4% of cases. Sedation was continuous until death for 98.1% of the cases. Probable sedation had a higher failure rate than proven sedation. Significant differences existed for the palliative care unit compared to other units regarding information to the patient, their consent, anticipation, mention by correspondence and carrying out titrations. When patients had already been treated with midazolam, the induction doses, initial maintenance doses, and doses at the time of death were significantly higher. For those receiving opioids, the maintenance dose at the time of death was higher. No comparison found a difference in overall survival. CONCLUSIONS After a sufficient follow-up has enabled teams to familiarize with this new legislation, reflection on sedation should be conducted to adapt to final recommendations.
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Affiliation(s)
- Vincent Gamblin
- Palliative care unit, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France.
| | - Vincent Berry
- Palliative care unit, Maison Médicale Jean XXIII, 3 Place Erasme de Rotterdam, 59160, Lille, France
| | - Emmanuelle Tresch-Bruneel
- Direction of Research and Innovation, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - Michel Reich
- Palliative care unit, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - Arlette Da Silva
- Palliative care unit, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - Stéphanie Villet
- Palliative care unit, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France
| | - Nicolas Penel
- Direction of Research and Innovation, Oscar Lambret center, 3 rue Frédéric Combemale, 59020, Lille, France
- Lille University Hospital and Medical School, 59000, Lille, France
| | - Chloé Prod'Homme
- Lille University Hospital and Medical School, Palliative care unit, 59000, Lille, France
- ETHICS (Experiment, Transhumanism, Human Interactions, Care and Society) - EA 7446, Lille Catholic University, 59800, Lille, France
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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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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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Curseen KA, Taj J, Grant Q. Pain Management in Patients with Serious Illness. Med Clin North Am 2020; 104:415-438. [PMID: 32312407 DOI: 10.1016/j.mcna.2020.01.005] [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: 11/25/2022]
Abstract
Managing pain in patients with serious illness can be complex. However, pain is often a prominent symptom in patients with malignant and nonmalignant serious illness and providers have to be adept at balancing effective pain management and safety. Clinicians should start with a standard pain assessment that lays important groundwork for developing a tailored multimodal approach to pain management. It is important to identify physical causes of pain and also existential causes. Opioids are not always appropriate but are still an important tool for managing pain. Basic opioid management and safe practices are essential when managing this population.
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Affiliation(s)
- Kimberly Angelia Curseen
- Internal Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA.
| | - Jabeen Taj
- Hospice and Palliative Medicine, Cardiac Palliative Care, Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory University Hospital, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
| | - Quintesia Grant
- Palliative and Supportive Care, Grady Memorial Hospital, Harbor Grace Hospice, Atlanta, GA, USA; Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
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Wright DK, Gastmans C, Vandyk A, de Casterlé BD. Moral identity and palliative sedation: A systematic review of normative nursing literature. Nurs Ethics 2019; 27:868-886. [DOI: 10.1177/0969733019876312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.
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Rodrigues P, Menten J, Gastmans C. Physicians' perceptions of palliative sedation for existential suffering: a systematic review. BMJ Support Palliat Care 2019; 10:136-144. [PMID: 31481477 DOI: 10.1136/bmjspcare-2019-001865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Palliative sedation for existential suffering (PS-ES) is a controversial clinical intervention. Empirical studies about physicians' perceptions do not converge in a clear position and current clinical practice guidelines do not agree either regarding this kind of intervention. AIM To gain deeper insight into physicians' perceptions of PS-ES, the factors influencing it, the conditions for implementing it and the alternatives to it. DESIGN Systematic review of qualitative, quantitative and mixed-methods studies following the Peer Review Electronic Search Strategies and Preferred Reporting Items for Systematic Reviews and Meta-analyses protocols; quality appraisal and thematic synthesis methodology. DATA SOURCES Seven electronic databases (PubMed, CINAHL, Embase, Scopus, Web of Science, PsycINFO, PsycARTICLES) were exhaustively searched from inception through March 2019. Two reviewers screened paper titles, abstracts and full texts. We included only peer-reviewed journal articles published in English, French, German, Dutch, Spanish, Italian or Portuguese that focused on physicians' perceptions of PS-ES. RESULTS The search yielded 17 publications published between 2002 and 2017. Physicians do not hold clear views or agree if and when PS-ES is appropriate. Case-related and individual-related factors that influenced physicians' perceptions were identified. There is still no consensus regarding criteria to distinguish between necessary and sufficient conditions for invoking PS-ES. Some alternatives to PS-ES were identified. CONCLUSIONS To date, there is still no consensus on physicians' perceptions of PS-ES. Further research is necessary to understand factors that influence physicians' perceptions and philosophical-ethical presuppositions underlying this perceptions.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS 7446 - Centre d'éthique médicale, Université Catholique de Lille, Lille, France
| | - Johan Menten
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Chris Gastmans
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Tarbi EC, Meghani SH. A concept analysis of the existential experience of adults with advanced cancer. Nurs Outlook 2019; 67:540-557. [PMID: 31040052 PMCID: PMC6764914 DOI: 10.1016/j.outlook.2019.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/04/2019] [Accepted: 03/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Attention to the existential dimension of an individual's experience during serious illness is important. However, existential concerns continue to be poorly defined in literature, leading to neglect in the clinical realm. PURPOSE This concept analysis seeks to clarify the concept of the existential experience within the context of adults with advanced cancer. METHODS Rodgers' evolutionary method of concept analysis was used. DISCUSSION Existential experience in adults with advanced cancer is a dynamic state, preceded by confronting mortality, defined by diverse reactions to shared existential challenges related to the parameters of existence (body, time, others, and death), resulting in a dialectical movement between existential suffering and existential health, with capacity for personal growth. Personal factors and the ability to cope appear to influence this experience. CONCLUSION These findings can drive future research and enhance clinician ability to attend to the existential domain, thereby improving patient experience at end-of-life.
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Affiliation(s)
- Elise C Tarbi
- University of Pennsylvania School of Nursing, Philadelphia, PA.
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Alavi NM, Hosseini F. Educating the Existential View to Nurses in Cancer Care: A Review. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2019; 24:243-250. [PMID: 31333736 PMCID: PMC6621502 DOI: 10.4103/ijnmr.ijnmr_108_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The aim of this study was to review the interventional studies about educating existential concepts to the nurses working in cancer care. Materials and Methods: In this systematic narrative review, the papers published in English and Farsi databases of PubMed, Elsevier, web of since, Scopus, ProQuest, ERIC, Google Scholar and Ovid, MagIran and SID, from 1990 to 2018 were reviewed. Methodological quality of the studies was independently assessed by, using checklists developed by Greenhalgh, and Cochrane Center. No statistical pooling of the outcomes was performed, due to heterogeneity of the outcomes. Results: After wide search, the 17 studies entered to this narrative study. The results showed that educating the existential concept to the nurses dealing with cancer patients can improve their self-competency in providing efficient care to these patients and their ability in decision making. It also enhances their quality of life and decreases the death anxiety and emotional exhaustion. Conclusions: There were limited and low quality interventional studies about the effects of educating existential concepts to the nurses dealing with cancer patients. These studies showed that knowing this philosophy can help nurses to address caring needs of cancer patients more efficiently. The specific method or content of education cannot be recommended because of the large differences in the methodologies between the studies.
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Affiliation(s)
- Negin Masoudi Alavi
- Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Fatemeh Hosseini
- Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
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Kioko PM, Requena Meana P. The nature of suffering and its relief: a proposal for a redefinition. BMJ Support Palliat Care 2019; 10:e1. [DOI: 10.1136/bmjspcare-2019-001796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/03/2019] [Accepted: 04/22/2019] [Indexed: 12/16/2022]
Abstract
Recent advances in our understanding of the nature of suffering and its different dimensions have exposed certain deficits in the current definition of suffering. These shortcomings have impacted negatively on the appropriate formulation of precise treatment objectives for each dimension of suffering within the overall framework of the goals of medicine. Existential suffering offers a clear example where the lack of a universally accepted definition has led to confusion regarding what should constitute appropriate relief for this particular dimension of suffering. In this thought piece, we propose a redefinition of suffering based on three elements: first, suffering refers to a specific state of a person (the essence of suffering); second, this state is characterised by a specific psychosomatic anguish reaction (the manifestation of suffering) and third, this reaction is in response to a perceived threat to the integrity of the person (the cause of suffering). The proposed definition allows for an important and clear distinction to be made between the primary and symptomatic relief of suffering and the role of medicine in each form of relief. The terms of the proposed definition and the distinction between primary and symptomatic relief provide useful tools for further research regarding the different dimensions of suffering and its relief.
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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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Rousseau PC. Recent Literature. J Palliat Med 2018. [DOI: 10.1089/jpm.2018.0498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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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Bozzaro C, Schildmann J. "Suffering" in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice. J Pain Symptom Manage 2018; 56:288-294. [PMID: 29689298 DOI: 10.1016/j.jpainsymman.2018.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 11/19/2022]
Abstract
Palliative sedation is an increasingly used and, simultaneously, challenging practice at the end of life. Many controversies associated with this therapy are rooted in implicit differences regarding the understanding of "suffering" as a prerequisite for palliative sedation. The aim of this study is to inform the current debates by a conceptual analysis of two different philosophical accounts of suffering-1) the subjective and holistic concept and 2) the objective and gradual concept-and by a clinical-ethical analysis of the implications of each account for decisions about palliative sedation. We will show that although the subjective and holistic account of suffering fits well with the holistic approach of palliative care, there are considerable challenges to justify limits to requests for palliative sedation. By contrast, the objective and gradual account fits well with the need for an objective basis for clinical decisions in the context of palliative sedation but runs the risk of falling short when considering the individual and subjective experience of suffering at the end of life. We will conclude with a plea for the necessity of further combined conceptual and empirical research to develop a sound and feasible understanding of suffering, which can contribute to consistent decision making about palliative sedation.
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Affiliation(s)
- Claudia Bozzaro
- Department of Medical Ethics and History of Medicine, Albert-Ludwigs-University, Freiburg, Germany.
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- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2018. [DOI: 10.1089/jpm.2018.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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