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Garcia Romo E, Pfang B, Valle Borrego B, Lobo Antuña M, Noguera Tejedor A, Rubio Gomez S, Galindo Vazquez V, Prieto Rios B. Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms. J Palliat Med 2024. [PMID: 38973718 DOI: 10.1089/jpm.2023.0672] [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: 07/09/2024] Open
Abstract
Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.
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Affiliation(s)
- Eduardo Garcia Romo
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Bernadette Pfang
- Health Research Institute of the Jimenez Diaz Foundation, Madrid, Spain
| | | | | | | | - Silvia Rubio Gomez
- Palliative Care Unit, Beata María Ana de Hermanas Hospitalarias Hospital, Madrid, Spain
| | | | - Blanca Prieto Rios
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Kawashima N, Yokomichi N, Morita T, Yabuki R, Hisanaga T, Imai K, Hirose Y, Shimokawa M, Miwa S, Yamauchi T, Okamoto S, Satomi E. Comparison of Pharmacological Treatments for Agitated Delirium in the Last Days of Life. J Pain Symptom Manage 2024; 67:441-452.e3. [PMID: 38355071 DOI: 10.1016/j.jpainsymman.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT Antipsychotics are often used in managing symptoms of terminal delirium, but evidence is limited. OBJECTIVES To explore the comparative effectiveness of haloperidol with as-needed benzodiazepines (HPD) vs. chlorpromazine (CPZ) vs. levomepromazine (LPZ) for agitated delirium in the last days. METHODS A prospective observational study was conducted in two palliative care units in Japan. Adult cancer patients who developed agitated delirium with a modified Richmond Agitation-Sedation Scale (RASS-PAL) of one or more were included; palliative care specialist physicians determined that the etiology was irreversible; and estimated survival was 3 weeks or less. Patients treated with HPD, CPZ, or LPZ were analyzed. We measured RASS, NuDESC, Agitation Distress Scale (ADS), and Communication Capacity Scale (CCS) on Days 1 and 3. RESULTS A total of 277 patients were enrolled, and 214 were analyzed (112 in HPD, 50 in CPZ, and 52 in LPZ). In all groups, the mean RASS-PAL score significantly decreased on Day 3 (1.37 to -1.01, 1.87 to -1.04, 1.79 to -0.62, respectively; P < 0.001); the NuDESC and ADS scores also significantly decreased. The percentages of patients with moderate to severe agitation and those with full communication capacity on Day 3 were not significantly different. The treatments were well-tolerated. While one-fourth of HPD group changed antipsychotics, 88% or more of CPZ and LPZ groups continued the initial antipsychotics. CONCLUSION Haloperidol with as-needed benzodiazepine, chlorpromazine, or levomepromazine may be effective and safe for terminal agitation. Chlorpromazine and levomepromazine may have an advantage of no need to change medications.
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Affiliation(s)
- Natsuki Kawashima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan; Department of Palliative and Supportive Care, University of Tsukuba Hospital, Tsukuba, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan; Research Association for Community Health, Hamamatsu, Japan
| | - Ritsuko Yabuki
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yumi Hirose
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Miho Shimokawa
- Department of Palliative Care, Tsukuba Central Hospital, Ushiku, Japan
| | - Satoru Miwa
- Seirei Hospice, Seirei Miyahara General Hospital, Hamamatsu, Japan
| | | | | | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
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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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Mercadante S, Villari P, David F. Palliative sedation outside a palliative care unit. BMJ Support Palliat Care 2023; 13:e297-e299. [PMID: 33597167 DOI: 10.1136/bmjspcare-2020-002494] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 02/08/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE The need of acute transition from an intensive care setting to an end-of-life setting requires collaboration and experience. Variable information exists on palliative sedation in traditional palliative care settings, including home care, hospices or palliative care units. MATERIALS Four cases which required a rapid decision-making to alleviate suffering in patients close to death are described. RESULTS Despite having different clinical pathways leading to intensive but medically non-beneficial treatments, patients were converted to a rapid transition of care in the unit where they had been admitted, due to different logistic reasons. An appropriate discussion with relatives about the short prognosis and the need to sedate for controlling suffering in the last hours of life was fundamental in preventing further suffering with intensive treatments. CONCLUSIONS These clinical notes suggest that palliative care and end-of-life measures should be also expanded in other settings, where palliative care issues are traditionally not properly assessed, implementing the collaboration with other colleagues with different clinical extractions.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Supportive Care, Private Hospital La Maddalena, Palermo, Sicilia, Italy
| | - Patrizia Villari
- Anesthesia, Private Hospital La Maddalena, Palermo, Sicilia, Italy
| | - Fabrizio David
- Anesthesia, Private Hospital La Maddalena, Palermo, Sicilia, Italy
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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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Kauzner S, Heckel M, Ostgathe C, Schneider M, Bausewein C, Schildmann E, Kremling A, Ziegler K, Klein C. Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates. J Palliat Med 2023; 26:1277-1284. [PMID: 37155703 DOI: 10.1089/jpm.2022.0476] [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: 05/10/2023] Open
Abstract
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.
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Affiliation(s)
- Saskia Kauzner
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuela Schneider
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care and Charité Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Lojo-Cruz C, Mora-Delgado J, Rivas Jiménez V, Carmona Espinazo F, López-Sáez JB. Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription. J Clin Med 2023; 12:5187. [PMID: 37629229 PMCID: PMC10455353 DOI: 10.3390/jcm12165187] [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: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.
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Affiliation(s)
- Cristina Lojo-Cruz
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Juan Mora-Delgado
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Víctor Rivas Jiménez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Fernando Carmona Espinazo
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerta del Mar, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Juan-Bosco López-Sáez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerto Real, Calle Romería 7, 11510 Puerto Real, Spain;
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Newcomer K, Merkelz K, Tatum P, Dalton H. Palliative Sedation in the Home Setting #451. J Palliat Med 2023; 26:299-300. [PMID: 36724321 DOI: 10.1089/jpm.2022.0508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Kelley Newcomer
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Kurt Merkelz
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Paul Tatum
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Heather Dalton
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
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Garcia ACM, Isidoro GM, Paiva EMDC, Silva AE, Costa ICP, Bornemann-Cimenti H. Palliative Sedation at Home: A Scoping Review. Am J Hosp Palliat Care 2023; 40:173-182. [PMID: 35466700 DOI: 10.1177/10499091221096412] [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: 01/19/2023] Open
Abstract
Palliative Sedation (PS) is an effective measure for the relief of refractory symptoms in end-of-life patients. This intervention can be performed at home, respecting the patients' and their families' decisions. A scoping review was performed to map the available evidence in the literature on the performance of PS at home. This review included 23 studies. Most were conducted in European countries with adult cancer patients. Patients, family members and healthcare providers participated in the decision making regarding the use of PS at home. PS was used primarily to manage refractory symptoms (pain, delirium, dyspnea, and others), and in 1 of the studies PS was mentioned as a possible intervention for shortening life. The most commonly used medication was midazolam and the average duration ranged from 4 h to 7 days. There are few reports on adverse events related to PS. This intervention seems to be a feasible possibility for the management of refractory symptoms in patients at the end of life, despite the fact that it can represent specific challenges for healthcare providers, patients and families. However, the literature is limited regarding PS in children and in people with diseases other than cancer, as well as on the evaluation of possible adverse effects related to this intervention. Furthermore, it is essential to have a broad ethical, clinical and legal debate on whether to consider the use of PS for the purpose of shortening life in specific cases.
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Affiliation(s)
| | | | | | - Alexandre E Silva
- Nursing Department - Campus Centro-Oeste Dona Lindu, 74383Federal University of São João del-Rei, Divinópolis, Brazil
| | | | - Helmar Bornemann-Cimenti
- Departement of Anesthesiology and Intensive Care Medicine, 31475Medical University of Graz, Graz, Austria
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Li N, Cui M, Wang Y. Effect of Dexmedetomidine for Palliative Sedation for Refractory Dyspnoea in Patients with Terminal-Stage Cancer. Cancer Manag Res 2023; 15:291-299. [PMID: 36987523 PMCID: PMC10040164 DOI: 10.2147/cmar.s404934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Background Dyspnoea affects a considerable percentage of patients with terminal-stage cancer, and clinical guidelines recommend palliative sedation for patients with refractory dyspnoea. Midazolam is currently the most commonly used sedative; however, it can cause serious adverse reactions, such as respiratory/circulatory depression. Hence, there is a need for an alternative sedative. Dexmedetomidine (DEX) is a promising alternative as its "awake sedation" effect; however, little is known regarding its use in patients with end-stage dyspnoea. Therefore, the aim of this study was to determine the safety and usefulness of DEX for palliative sedation of patients with refractory dyspnoea. Methods This retrospective study included patients with terminal-stage cancer who received DEX for palliative sedation owing to refractory dyspnoea in the hospice ward from January 2018 to October 2022. We analysed their general data, dyspnoea conditions, sedation details, sedative treatment effect, dyspnoea relief, and changes in vital signs before and after sedation, via paired t-tests. Results We included 17 patients with terminal-stage cancer who received DEX palliative sedation at a dose of 0.2-0.9 µg/kg·h for refractory dyspnoea, among whom 6 (35%) received a loading dose of 1 µg/kg in 10 min. After 1 h of sedation and at the maximum sedation dose, the Respiratory Distress Observation Scale and Richmond Agitation-Sedation Scale scores decreased significantly compared with those before sedation (all P<0.001), as did the respiratory rate (P=0.024 and P=0.008, respectively). The heart rate and blood oxygen saturation did not significantly change, whereas the systolic and diastolic blood pressure after 1 h of sedation were significantly lower than those before sedation (both P=0.015). Conclusion DEX is a promising palliative sedative for patients with terminal-stage cancer, as it safely relieved the symptoms of refractory dyspnoea without inducing serious adverse reactions. Therefore, DEX may greatly enhance the quality of life for patients with terminal-stage cancer.
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Affiliation(s)
- Na Li
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Meng Cui
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
- Correspondence: Meng Cui; Yumei Wang, Department of Hospice Care, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang, Liaoning, People’s Republic of China, Tel +86 18940254587; +86 18940251490, Email ;
| | - Yumei Wang
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
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Meesters S, Bazata J, Handtke V, Gehrmann J, Kurkowski S, Klein C, Bausewein C, Schildmann E. "It's pretty much flying blind in the home care setting": A qualitative study on the influence of home care specific circumstances on sedation in specialist palliative home care. Palliat Med 2023; 37:140-148. [PMID: 36242514 PMCID: PMC9841818 DOI: 10.1177/02692163221128938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Existing data on sedation at the end of life indicate challenges in the home care setting, leading to deviations from guidelines or non-provision of sedation. AIM As part of the "SedPall" study, we aimed to explore circumstances in specialist palliative home care, which influence the practice of sedation. DESIGN Semi-structured qualitative interviews (n = 59) and two focus groups (n = 4, n = 5). Recruitment took place via contact persons. We thematically analyzed the transcripts with the Framework Approach, using MAXQDA 2018.2. SETTING/PARTICIPANTS Physicians, nurses, and other members of the multiprofessional team from 10 palliative care units and seven home care teams. RESULTS Participants reported home care specific circumstances that can be categorized into three interrelated topics. (1) Lack of 24/7 on-site availability, (2) active involvement of the family, (3) challenges regarding teamwork and multidisciplinarity. Participants drew different conclusions from the reported circumstances regarding the feasibility of different types of sedation at home: While some reported to generally use all types of sedation, others stated that some types of sedation are not feasible in home care, for example deep sedation until death. Most participants questioned the applicability of existing sedation guidelines in the home care setting. CONCLUSION Our data indicate that sedation practices might currently follow the healthcare professional's attitude or service policy rather than the patient's need. To avoid hospital admission in manageable cases and ensure that home care specific best practice standards are met, existing guideline recommendations have to be adapted and supplemented by additional supporting measures specific for the home care setting.
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Affiliation(s)
- Sophie Meesters
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany.,Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jeremias Bazata
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany
| | - Violet Handtke
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany
| | - Jan Gehrmann
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany.,TUM School of Medicine, Institute of General Practice and Health Services Research, Technical University of Munich, Munich, Germany
| | - Sandra Kurkowski
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Eva Schildmann
- Department of Palliative Medicine, LMU Klinikum, 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
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12
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Hwang IC. Current Status and Future Directions of Research on Palliative Sedation. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:193-197. [PMID: 37674671 PMCID: PMC10179994 DOI: 10.14475/jhpc.2022.25.4.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 09/08/2023]
Abstract
Patients with terminal cancer experience very severe symptoms during the end of life, and palliative sedation (PS) may be considered if those symptoms are refractory to any other treatment. This brief report presents ethical considerations, practices, and recent concerns on PS. PS is quite different from euthanasia. There is a lack of consensus and standards on protocols, but its notable effects have been reported in hospice care settings. Most studies to date have reported no difference in survival between patients receiving PS and those not, and PS must be conducted proportionally with the lightest level of sedation. The most common indication for PS is delirium, and midazolam is the main sedative used. It is recommended that information regarding PS should be provided to patients and their caregivers repeatedly as early as possible. Existential suffering alone is not an indication for PS, and there is a lack of evidence on bispectral analysis. Additional research on PS is needed in Korea.
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Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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13
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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] [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, College of Medicine, Chungnam National University, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Young-Woong Won
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
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Belar A, Arantzamendi M, Menten J, Payne S, Hasselaar J, Centeno C. The Decision-Making Process for Palliative Sedation for Patients with Advanced Cancer-Analysis from a Systematic Review of Prospective Studies. Cancers (Basel) 2022; 14:301. [PMID: 35053464 PMCID: PMC8773810 DOI: 10.3390/cancers14020301] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The involvement of patients in decision making about their healthcare plans is being emphasized. In the context of palliative sedation, it is unclear how these decisions are made and who are involved in. The aim of the study is to understand how this decision-making is taken. METHOD Information from a systematic review on clinical aspects of palliative sedation prospective studies were included. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019). Data extraction and analysis regarded: (a) When and by whom the decision-making process is initiated; (b) patient involvement; (c) family involvement and (d) healthcare involvement. RESULTS Data about decision making were reported in 8/10 included articles. Palliative sedation was reported in 1137 patients (only 16 of them were non-cancer). Palliative sedation was introduced by the palliative care team during the disease process, at admission, or when patients experienced refractory symptoms. Only two studies explicitly mentioned the involvement of patients in decision making. Co-decision between families and the regular health care professionals was usual, and the health care professionals involved had been working in palliative care services. CONCLUSION Patient participation in decision making appeared to be compromised by limited physical or cognitive capacity and family participation is described. The possibility of palliative sedation should be discussed earlier in the disease process.
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Affiliation(s)
- Alazne Belar
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Maria Arantzamendi
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit, 3000 Leuven, Belgium;
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster LA1 4YW, UK;
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Carlos Centeno
- Institute for Culture and Society-Atlantes, Universidad de Navarra, 31009 Pamplona, Spain; (A.B.); (C.C.)
- IdiSNA—Instituto de Investigacion Sanitaria de Navarra, 31008 Pamplona, Spain
- Departamento Medicina Paliativa, Clínica Universidad de Navarra, 31001 Pamplona, Spain
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Carvalho RTD, Crispim DH, Franck EM, Dei Santi DB, Anagusko SS, Fukuda MV, Cavalcante LSB, Jales SMDCP, Queiroz MEGD, Bonfá ESDDO. Palliative care in the COVID-19 pandemic: Strategy of HCFMUSP. Clinics (Sao Paulo) 2022; 77:100050. [PMID: 35662009 PMCID: PMC9110651 DOI: 10.1016/j.clinsp.2022.100050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/06/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ricardo Tavares de Carvalho
- Coordinator of Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil
| | - Douglas Henrique Crispim
- Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil
| | - Ednalda Maria Franck
- Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil.
| | - Daniel Battacini Dei Santi
- Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil
| | - Sergio Seiki Anagusko
- Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil
| | - Márcio Veronesi Fukuda
- Department of Palliative Care, Hospital das Clínicas, Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brazil
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16
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Ahn HK, Ahn HY, Park SJ, Hwang IC. Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:254-260. [PMID: 37674644 PMCID: PMC10180067 DOI: 10.14475/jhpc.2021.24.4.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/30/2021] [Indexed: 09/08/2023]
Abstract
Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.
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Affiliation(s)
- Hee Kyung Ahn
- Oncology Division, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Korea
| | | | - In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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17
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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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18
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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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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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20
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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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Abstract
Terminal delirium is a common occurrence in patients at the end of life, and its presence is widely accepted as a poor prognostic indicator. The hyperactive subtype is characterized by psychomotor agitation that is distressing to patients, caregivers, and providers. The purpose of this study was to determine whether physical, psychosocial, or spiritual data collected at hospice admission are associated with development of hyperactive terminal delirium. In this retrospective cohort study, 154 patients were assigned to one of two cohorts depending on whether or not they had signs of hyperactive terminal delirium. Hospice admission data from the Hospice Item Set, psychosocial assessment, and spiritual assessment were analyzed using descriptive statistics, inferential statistics, and logistic regression. Although there were no statistically significant relationships among the physical, psychosocial, and spiritual variables and hyperactive terminal delirium, there were some findings that are clinically significant for nurses caring for patients at the end of life. Specifically, this study highlights the importance of ongoing physical, psychosocial, and spiritual assessment throughout the end-of-life trajectory, as well as prompt management of symptoms.
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22
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Krooupa AM, Vivat B, McKeever S, Marcus E, Sawyer J, Stone P. Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE. Palliat Med 2020; 34:83-113. [PMID: 31434526 PMCID: PMC6952953 DOI: 10.1177/0269216319871666] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of observational measures to assess palliative care patients' level of consciousness may improve patient care and comfort. However, there is limited knowledge regarding the validity and reliability of these measures in palliative care settings. AIM To identify and evaluate the psychometric performance of observational level of consciousness measures used in palliative care. DESIGN Systematic review; PROSPERO registration: CRD42017073080. DATA SOURCES We searched six databases until November 2018, using search terms combining subject headings and free-text terms. Psychometric performance for each identified tool was appraised independently by two reviewers following established criteria for developing and evaluating health outcome measures. RESULTS We found 35 different levels of consciousness tools used in 65 studies. Only seven studies reported information about psychometric performance of just eight tools. All other studies used either ad hoc measures for which no formal validation had been undertaken (n = 21) or established tools mainly developed and validated in non-palliative care settings (n = 37). The Consciousness Scale for Palliative Care and a modified version of the Richmond Agitation-Sedation Scale received the highest ratings in our appraisal, but, since psychometric evidence was limited, no tool could be assessed for all psychometric properties. CONCLUSION An increasing number of studies in palliative care are using observational measures of level of consciousness. However, only a few of these tools have been tested for their psychometric performance in that context. Future research in this area should validate and/or refine the existing measures, rather than developing new tools.
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Affiliation(s)
- Anna-Maria Krooupa
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Stephen McKeever
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK.,school of Nursing, Faculty of Health, Social Care and Education, Kingston Hill, UK
| | - Elena Marcus
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Joseph Sawyer
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
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23
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Ingravallo F, de Nooijer K, Pucci V, Casini C, Miccinesi G, Rietjens JAC, Morino P. Discussions about palliative sedation in hospice: Frequency, timing and factors associated with patient involvement. Eur J Cancer Care (Engl) 2019; 28:e13019. [DOI: 10.1111/ecc.13019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/04/2018] [Accepted: 01/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Kim de Nooijer
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Valentina Pucci
- Department of Medical and Surgical Sciences (DIMEC)University of Bologna Bologna Italy
| | - Cinzia Casini
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
| | - Guido Miccinesi
- Clinical Epidemiology UnitOncological network, prevention and research Institute (ISPRO) Florence Italy
| | - Judith A. C. Rietjens
- Department of Public HealthErasmus University Medical Center Rotterdam the Netherlands
| | - Piero Morino
- Palliative Care Coordination, Toscana Centrale Local Health TrustHospice Convento delle Oblate Florence Italy
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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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25
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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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