Sedation for refractory symptoms of terminal cancer patients in Taiwan

Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription

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.

Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study

OBJECTIVE

Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan.

METHODS

Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries.

RESULTS

A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001).

CONCLUSIONS

Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.

Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study

BACKGROUND

Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors.

AIM

We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries.

DESIGN

This is an international multicenter prospective cohort study.

SETTING/PARTICIPANTS

Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country.

RESULTS

A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan.

CONCLUSIONS

This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care.

Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature

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.

Association between continuous deep sedation and survival time in terminally ill cancer patients

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.

Palliative Sedation in Terminal Cancer Patients Admitted to Hospice or Home Care Programs: Does the Setting Matter? Results From a National Multicenter Observational Study

CONTEXT

Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking.

OBJECTIVES

Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process, and clinical aspects of PS.

METHODS

About 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness were registered every eight hours to death.

RESULTS

About 4276 patients were screened, 2894 followed till death, and 531 (18%) underwent PS. PS rate was 15% in HC and 21% in HS (P < 0.001). Principal refractory symptoms were delirium (54%) and dyspnea (45%), respectively, more common in HC (P < 0.001) and HS (P = 0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug (94% HS vs. 75% HC; P < 0.001) mainly by continuous infusion (74% HC vs. 89% HS; P < 0.001). PS duration was less than 48 hours in 67% of patients. Hydration during PS was less frequent in HC (27% vs. 49%; P < 0.001). In the eight hours before death, consciousness level was unrousable to mild physical stimulation in 81% and symptom control complete in 89% of cases.

CONCLUSION

Our results show feasibility of PS in HC and HS and suggest setting differences in rates, indications, and practice of PS, possibly related to patients' selection or care organization.

Suboptimal palliative sedation in primary care: an exploration

OBJECTIVES

Palliative sedation is a therapeutic option to control refractory symptoms in terminal palliative patients. This study aims at describing the occurrence and characteristics of suboptimal palliative sedations in primary care and at exploring the way general practitioners (GPs) experience suboptimal palliative sedation in their practice.

METHODS

We conducted a mixed methods study with a quantitative prospective survey in primary care and qualitative semi-structured interviews with GPs. The research team defined suboptimal palliative sedation as a time interval until deep sleep >1.5 h and/ or >2 awakenings after the start of the unconsciousness. Descriptive statistics were calculated on the quantitative data. Thematic analysis was used to analyse interview transcripts.

RESULTS

We registered 63 palliative sedations in 1181 home deaths, 27 forms were completed. Eleven palliative sedations were suboptimal: eight due to the long time span until deep sleep; three due the number of unintended awakenings. GPs' interview analysis revealed two major themes: the shifting perception of failure and the burden of responsibility.

CONCLUSIONS

Suboptimal palliative sedation occurs frequently in primary palliative care. Efficient communication towards family members is needed to prevent them from having unrealistic expectations and to prevent putting pressure on the GP to hasten the procedure. Sharing the burden of decision-making during the procedure with other health care professionals might diminish the heavy responsibility as perceived by GPs.

International variations in clinical practice guidelines for palliative sedation: a systematic review

OBJECTIVES

Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument.

METHODS

Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016.

RESULTS

Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations.

CONCLUSIONS

Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.

A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications

Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner.

To explore the relationship between the use of midazolam and cessation of oral intake in the terminal phase of hospice inpatients: A retrospective case note review: Does midazolam affect oral intake in the dying?

BACKGROUND

Sedative drugs are used to improve comfort in dying patients but have been accused of shortening survival by reducing patients' ability to maintain nutrition and hydration. However, as part of the dying process, patients in the last days of life often have impaired conscious levels and an inability to maintain oral intake.

AIM

To establish whether the decline in oral intake is related to the use of midazolam in the last week of life.

DESIGN

This is a retrospective case note review.

SETTING/PARTICIPANTS

The data were obtained from nursing records and medication charts of 125 consecutive hospice inpatients who died at a hospice in South London.

RESULTS

A total of 72 patients received midazolam on one or more days within the last 7 days of life (midazolam group) and 49 patients received no midazolam (control group).

CONCLUSION

Mean oral intake was reduced 7 days prior to death and declined sequentially over subsequent days in both patient groups. More patients required midazolam as death approached and most patients received midazolam for less than 3 days. Mean doses of midazolam used were low. Patients in the midazolam group had lower oral intake than those in the control group, but this association does not indicate causation.

The Ethics of Palliative Sedation as a Therapy of Last Resort

Many patients nearing the end of life reach a point at which the goals of care change from an emphasis on prolonging life and optimizing function to maximizing the quality of remaining life, and palliative care becomes a priority. For some patients, however, even high-quality aggressive palliative care fails to provide relief. For patients suffering from severe pain, dyspnea, vomiting, or other symptoms that prove refractory to treatment, there is a consensus that palliative sedation is an appropriate intervention of last resort. In this report, the National Ethics Committee, Veterans Health Administration examines what is meant by palliative sedation, explores ethical concerns about the practice, reviews the emerging professional consensus regarding the use of palliative sedation for managing severe, refractory symptoms at the end of life, and offers specific recommendations for institutional policy.

A Protocol for the Control of Agitation in Palliative Care

Background:

Agitation is a distressing and dangerous behavior for all involved.

Objective:

To study a protocol effectiveness and safety.

Methods:

The time when the protocol was initiated and when the agitation was controlled, the number of doses needed and the complications observed were recorded.

Results:

One hundred and thirty-five inpatients of a palliative care service were included. The most frequent diagnosis was head and neck cancer, 37 (27%). The protocol was used 584 times, from 1 to 31 times on each patient, median of 3 times. Five hundred and thirty-four (91%) agitation episodes were controlled with only the first dose of the protocol, without significant complications.

Conclusion:

From those results, it can be said that this protocol is effective and safe.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit

Background

Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients.

Methods

This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a “Symptom Reporting Form”. Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups).

Results

One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time.

Conclusions

We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

Addressing Palliative Sedation during Expert Consultation: A Descriptive Analysis of the Practice of Dutch Palliative Care Consultation Teams

Main Objective

Since palliative sedation is considered a complex intervention, consultation teams are increasingly established to support general practice. This study aims to offer insight into the frequency and characteristics of expert consultations regarding palliative sedation.

Methods

We performed a retrospective analysis of a longitudinal database. This database contained all patient-related consultations by Dutch Palliative Care Consultation teams, that were requested between 2004 and 2011. We described the frequency and characteristics of these consultations, in particular of the subgroup of consultations in which palliative sedation was addressed (i.e. PSa consultations). We used multivariate regression analysis to explore consultation characteristics associated with a higher likelihood of PSa consultations.

Main Results and Their Significance

Of the 44,443 initial consultations, most were requested by general practitioners (73%) and most concerned patients with cancer (86%). Palliative sedation was addressed in 18.1% of all consultations. Palliative sedation was relatively more often discussed during consultations for patients with a neurologic disease (OR 1.79; 95% CI: 1.51–2.12) or COPD (OR 1.39; 95% CI: 1.15–1.69) than for patients with cancer. We observed a higher likelihood of PSa consultations if the following topics were also addressed during consultation: dyspnoea (OR 1.30; 95% CI: 1.22–1.40), agitation/delirium (OR 1.57; 95% CI: 1.47–1.68), exhaustion (OR 2.89; 95% CI: 2.61–3.20), euthanasia-related questions (OR 2.65; 95% CI: 2.37–2.96) or existential issues (OR 1.55; 95% CI: 1.31–1.83).

Conclusion

In conclusion, PSa consultations accounted for almost one-fifth of all expert consultations and were associated with several case-related characteristics. These characteristics may help clinicians in identifying patients at risk for a more complex disease trajectory at the end of life.

Pediatric Palliative Care in the Intensive Care Unit

The chronicity of illness that afflicts children in Pediatric Palliative Care and the medical technology that has improved their lifespan and quality of life make prognostication extremely difficult. The uncertainty of prognostication and the available medical technologies make both the neonatal intensive care unit and the pediatric intensive care unit locations where many children will receive Pediatric Palliative Care. Health care providers in the neonatal intensive care unit and pediatric intensive care unit should integrate fundamental Pediatric Palliative Care principles into their everyday practice.

Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China

Background

There are a number of studies dedicated to characteristics of sedation, but these studies are mostly bound to western country practices. The aim of this study is to describe the characteristics of patients who suffered from cancer and who had been sedated until their death in Shanghai, China.

Methods

Retrospective medical data of 244 terminally ill cancer patients including 82 sedated patients were collected. Data collected included demographic characteristics, disease-related characteristics and details of the sedation.

Results

In sedated cases, patients and/or caregivers gave the consent to start palliative sedation due to unmanageable symptoms. On average, sedation was performed 24.65(±1.78)hours before death. Agitated delirium and dyspnea were the most frequent indications for palliative sedation. There was no significant difference in survival time from admission till death between sedated and non-sedated patients (p > 0.05).

Conclusions

Palliative sedation is effective for reducing terminally ill cancer patients’ suffering without hastening death. Prospective research is needed to determine the optimal conditions for Chinese patients including indications, decision making process, informed consent, cultural and ethical issues, type of sedation and drugs.

Palliative pharmacological sedation for terminally ill adults

BACKGROUND

Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible.

OBJECTIVES

To assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014), and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interrupted-time-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively.

MAIN RESULTS

The searches resulted in 14 included studies, involving 4167 adults, of whom 1137 received palliative sedation. More than 95% of people had cancer. No studies were randomised or quasi-randomised. All were consecutive case series, with only three having prospective data collection. Risk of bias was high, due to lack of randomisation. No studies measured quality of life or participant well-being, which was the primary outcome of the review. Five studies measured symptom control, using four different methods, so pooling was not possible. The results demonstrated that despite sedation, delirium and dyspnoea were still troublesome symptoms in these people in the last few days of life. Control of other symptoms appeared to be similar in sedated and non-sedated people. Only one study measured unintended adverse effects of sedative drugs and found no major events; however, four of 70 participants appeared to have drug-induced delirium. The study noticed no respiratory suppression. Thirteen of the 14 studies measured survival time from admission or referral to death, and all demonstrated no statistically significant difference between sedated and non-sedated groups.

AUTHORS' CONCLUSIONS

There was insufficient evidence about the efficacy of palliative sedation in terms of a person's quality of life or symptom control. There was evidence that palliative sedation did not hasten death, which has been a concern of physicians and families in prescribing this treatment. However, this evidence comes from low quality studies, so should be interpreted with caution. Further studies that specifically measure the efficacy and quality of life in sedated people, compared with non-sedated people, and quantify adverse effects are required.

Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries

PURPOSE

The purpose of the study was to explore relatives' descriptions and experiences of continuous sedation in end-of-life care for cancer patients and to identify and explain differences between respondents from the Netherlands, Belgium, and the UK.

METHODS

In-depth interviews were held between January 2011 and May 2012 with 38 relatives of 32 cancer patients who received continuous sedation until death in hospitals, the community, and hospices/palliative care units.

RESULTS

Relatives' descriptions of the practice referred to the outcome, to practical aspects, and to the goals of sedation. While most relatives believed sedation had contributed to a 'good death' for the patient, yet many expressed concerns. These related to anxieties about the patient's wellbeing, their own wellbeing, and questions about whether continuous sedation had shortened the patient's life (mostly UK), or whether an alternative approach would have been better. Such concerns seemed to have been prompted by relatives witnessing unexpected events such as the patient coming to awareness during sedation. In the Netherlands and in Belgium, several relatives reported that the start of the sedation allowed for a planned moment of 'saying goodbye'. In contrast, UK relatives discerned neither an explicit point at which sedation was started nor a specific moment of farewell.

CONCLUSIONS

Relatives believed that sedation contributed to the patient having a good death. Nevertheless, they also expressed concerns that may have been provoked by unexpected events for which they were unprepared. There seems to exist differences in the process of saying goodbye between the NL/BE and the UK.

Estimating the potential life-shortening effect of continuous sedation until death: a comparison between two approaches

CONTEXT

In some cases, physicians estimate that continuous sedation until death may have a life shortening effect. The accuracy of these estimations can be questioned.

AIM

The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death.

METHODS

In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach (question: Did continuous sedation, according to your estimation,hasten the patient's death? If yes: by how much time?)and an indirect approach (estimated life expectancy minus duration of sedation). The intrarater agreement between both approaches was determined with a weighted κ.

RESULTS

According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%.The intrarater agreement between both approaches was fair (weighted κ=0.38). In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates.

CONCLUSIONS

The results show a discrepancy between different approaches to estimate the potential life shortening effect of continuous sedation until death.

The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland

OBJECTIVE

Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide.

METHOD

Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective.

RESULTS

The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation.

SIGNIFICANCE OF RESULTS

The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.

Dying with dementia: symptoms, treatment, and quality of life in the last week of life

CONTEXT

Burdensome symptoms present frequently in dementia at the end of life, but we know little about the symptom control provided, such as type and dosage of medication.

OBJECTIVES

To investigate symptom prevalence and prescribed treatment, explore associations with quality of life (QOL) in the last week of life, and examine symptom prevalence by cause of death of nursing home residents with dementia.

METHODS

Within two weeks after death, physicians completed questionnaires about symptoms and treatment in the last week for 330 nursing home residents with dementia in the Dutch End of Life in Dementia study (2007-2011). We used linear regression to assess associations with QOL, measured by the Quality of Life in Late-Stage Dementia scale. Causes of death were abstracted from death certificates.

RESULTS

Pain was the most common symptom (52%), followed by agitation (35%) and shortness of breath (35%). Pain and shortness of breath were mostly treated with opioids and agitation mainly with anxiolytics. At the day of death, 77% received opioids, with a median of 90 mg/24 hours (oral equivalents), and 21% received palliative sedation. Pain and agitation were associated with a lower QOL. Death from respiratory infection was associated with the largest symptom burden.

CONCLUSION

Symptoms are common in dementia at the end of life, despite the large majority of residents receiving opioids. Dosages may be suboptimal with regard to weighing of effects and side effects. Future research may employ observation on a day-to-day basis to better assess effectiveness of symptom control and possible side effects.

From sedation to continuous sedation until death: how has the conceptual basis of sedation in end-of-life care changed over time?

CONTEXT

Numerous attempts have been made to describe and define sedation in end-of-life care over time. However, confusion and inconsistency in the use of terms and definitions persevere in the literature, making interpretation, comparison, and extrapolation of many studies and case analyses problematic.

OBJECTIVES

This evidence review aims to address and account for the conceptual debate over the terminology and definitions ascribed to sedation at the end of life over time.

METHODS

Six electronic databases (MEDLINE, PubMed, Embase, AMED, CINAHL, and PsycINFO) and two high-impact journals (New England Journal of Medicine and the British Medical Journal) were searched for indexed materials published between 1945 and 2011. This search resulted in bibliographic data of 328 published outputs. Terms and definitions were manually scanned, coded, and linguistically analyzed by means of term description criteria and discourse analysis.

RESULTS

The review shows that terminology has evolved from simple to complex terms with definitions varying in length, comprising different aspects of sedation such as indications for use, pharmacology, patient symptomatology, target population, time of initiation, and ethical considerations, in combinations of a minimum of two or more of these aspects.

CONCLUSION

There is a pressing need to resolve the conceptual confusion that currently exists in the literature to bring clarity to the dialogue and build a base of commonality on which to design research and enhance the practice of sedation in end-of-life care.

Continuous sedation (CS) until death: mapping the literature by bibliometric analysis

CONTEXT

Sedation at the end of life, regardless of the nomenclature, is an increasingly debated practice at both clinical and bioethical levels. However, little is known about the characteristics and trends in scientific publications in this field of study.

OBJECTIVES

This article presents a bibliometric analysis of the scientific publications on continuous sedation until death.

METHODS

Four electronic databases (MEDLINE, PubMed, Embase, and PsycINFO®) were searched for the indexed material published between 1945 and 2011. This search resulted in bibliographic data of 273 published outputs that were analyzed using bibliometric techniques.

RESULTS

Data revealed a trend of increased scientific publication from the early 1990s. Published outputs, diverse in type (comments/letters, articles, reviews, case reports, editorials), were widely distributed across 94 journals of varying scientific disciplines (medicine, nursing, palliative care, law, ethics). Most journals (72.3%) were classified under Medical and Health Sciences, with the Journal of Pain and Symptom Management identified as the major journal in the field covering 12.1% of the total publications. Empirical research articles, mostly of a quantitative design, originated from 17 countries. Although Japan and The Netherlands were found to be the leaders in research article productivity, it was the U.K. and the U.S. that ranked top in terms of the quantity of published outputs.

CONCLUSION

This is the first bibliometric analysis on continuous sedation until death that can be used to inform future studies. Further research is needed to refine controversies on terminology and ethical acceptability of the practice, as well as conditions and modalities of its use.

Palliative sedation: a focus group study on the experiences of relatives

BACKGROUND

Most studies that have investigated the practice of palliative sedation have focused on physicians' practices and attitudes.

OBJECTIVE

The aim of this study was to explore relatives' experiences with palliative sedation and to gain more insight in positive and negative elements in their evaluation of palliative sedation.

DESIGN

Focus groups and individual interviews.

SETTING

Various care settings in the Netherlands.

SUBJECTS

A total of 14 relatives of patients who received palliative sedation until death participated.

RESULTS

Most relatives evaluated the provision of palliative sedation of their dying family member positively. Positive experiences were related to: the beneficial impact of palliative sedation on the patient's suffering, the opportunity that was offered to prepare for the patient's death, their involvement in the decision-making and care for the patient, and the pleasant care environment. However, the majority of the relatives were unsatisfied with one or more aspects of how information was being provided for. Some relatives were frustrated about the fact that nurses were not authorized to make decisions about the care for the patient and about the absence of physicians during weekends. None of the relatives mentioned the loss of the ability to communicate with the patient during the sedation and the possibility of "hastening death" as disadvantages of palliative sedation.

CONCLUSION

Relatives tend to evaluate the provision of palliative sedation to their severely suffering family member positively because it contributes to a peaceful dying process. However, relatives indicated discontent with how information was being provided and with the communication in general.

The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review

BACKGROUND

Palliative sedation is the intentional lowering of consciousness of a patient in the last phase of life to relieve suffering from refractory symptoms such as pain, delirium and dyspnoea.

AIM

In this systematic review, we evaluated the use of monitoring scales to assess the degree of control of refractory symptoms and/or the depth of the sedation.

DESIGN

A database search of PubMed and Embase was performed up to January 2010 using the search terms 'palliative sedation' OR 'terminal sedation'.

DATA SOURCES

Retro- and prospective studies as well as reviews and guidelines containing information about monitoring of palliative sedation, written in the English, German or Dutch language were included.

RESULTS

The search yielded 264 articles of which 30 were considered relevant. Most studies focused on monitoring refractory symptoms (pain, fatigue or delirium) or the level of awareness to control the level of sedation. Four prospective and one retrospective study used scales validated in other settings: the Numeric Pain Rating Scale, the Visual Analogue Scale, the Memorial Delirium Assessment Scale, the Communication Capacity Scale and Agitation Distress Scale. Only the Community Capacity Scale was partially validated for use in a palliative sedation setting. One guideline described the use of a scale validated in another setting.

CONCLUSIONS

A minority of studies reported the use of observational scales to monitor the effect of palliative sedation. Future studies should be focused on establishing proper instruments, most adequate frequency and timing of assessment, and interdisciplinary evaluation of sedation depth and symptom control for palliative sedation.

Palliative Sedation in Advanced Cancer Patients: Does it Shorten Survival Time? - A Systematic Review

BACKGROUND

Patients with advanced cancer often suffer from multiple refractory symptoms in the terminal phase of their life. Palliative sedation is one of the few ways to relieve this refractory suffering.

OBJECTIVES

This systematic review investigated the effect of palliative sedation on survival time in terminally ill cancer patients.

MATERIALS AND METHODS

Six electronic databases were searched for both prospective and retrospective studies which evaluated the effect of palliative sedation on survival time. Only those studies which had a comparison group that did not receive palliative sedation were selected for the review. Abstracts of all retrieved studies were screened to include the most relevant studies and only studies which met inclusion criteria were selected. References of all retrieved studies were also screened for relevant studies. Selected studies were assessed for quality and data extraction was done using the structured data extraction form.

RESULTS

Eleven studies including four prospective and seven retrospective studies were identified. Mean survival time (MST) was measured as the time from last admission until death. A careful analysis of the results of all the 11 studies indicated that MST of sedated and non-sedated group was not statistically different in any of the studies.

CONCLUSION

This systematic review supports the fact that palliative sedation does not shorten survival in terminally ill cancer patients. However, this conclusion needs to be taken with consideration of the methodology, study design, and the population studied of the included studies in this review.

Flemish palliative-care nurses’ attitudes to palliative sedation

Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses ( n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.

The experiences of relatives with the practice of palliative sedation: a systematic review

CONTEXT

Guidelines about palliative sedation typically include recommendations to protect the well-being of relatives.

OBJECTIVES

The aim of this study was to systematically review evidence on the experiences of relatives with the practice of palliative sedation.

METHODS

PubMed, Embase, Web of Science, PsycINFO, and CINAHL were searched for empirical studies on relatives' experiences with palliative sedation. We investigated relatives' involvement in the decision-making and sedation processes, whether they received adequate information and support, and relatives' emotions.

RESULTS

Of the 564 studies identified, 39 were included. The studies (30 quantitative, six qualitative, and three mixed methods) were conducted in 16 countries; three studies were based on relatives' reports, 26 on physicians' and nurses' proxy reports, seven on medical records, and three combined different sources. The 39 studies yielded a combined total of 8791 respondents or studied cases. Caregivers involved relatives in the decision making in 69%-100% of all cases (19 quantitative studies), and in 60%-100% of all cases, relatives were reported to have received adequate information (five quantitative studies). Only two quantitative studies reported on relatives' involvement in the provision of sedation. Despite the fact that the majority of relatives were reported to be comfortable with the use of palliative sedation (seven quantitative studies, four qualitative studies), several studies found that relatives were distressed by the use of sedation (five quantitative studies, five qualitative studies). No studies reported specifically about the support provided to the relatives.

CONCLUSION

Relatives' experiences with palliative sedation are mainly studied from the perspective of proxies, mostly professional caregivers. The majority of relatives seems to be comfortable with the use of palliative sedation; however, they may experience substantial distress by the use of sedation.

Pediatric palliative sedation therapy with propofol: recommendations based on experience in children with terminal cancer

BACKGROUND

The use of propofol for palliative sedation of children is not well documented.

OBJECTIVE

Here we describe our experience with the use of propofol palliative sedation therapy (PST) to alleviate intractable end-of-life suffering in three pediatric oncology patients, and propose an algorithm for the selection of such candidates for PST.

PATIENTS AND METHODS

We identified inpatients who had received propofol PST within 20 days of death at our institution between 2003 and 2010. Their medical records were reviewed for indicators of pain, suffering, and sedation from 48 hours before PST to the time of death. We also tabulated consumption of opioids and other symptom management medications, pain scores, and adverse events of propofol, and reviewed clinical notes for descriptors of suffering and/or palliation.

RESULTS

Three of 192 (1.6%) inpatients (aged 6-15 years) received propofol PST at the end of life. Consumption of opioids and other supportive medications decreased during PST in two cases. In the third case, pain scores remained high and sedation was the only effective comfort measure. Clinical notes suggested improved comfort and rest in all patients. Propofol infusions were continued until the time of death.

CONCLUSIONS

Our experience demonstrates that propofol PST is a useful palliative option for pediatric patients experiencing intractable suffering at the end of life. We describe an algorithm that can be used to identify such children who are candidates for PST.

Palliative sedation in end-of-life care and survival: a systematic review

PURPOSE

Palliative sedation is a clinical procedure aimed at relieving refractory symptoms in patients with advanced cancer. It has been suggested that sedative drugs may shorten life, but few studies exist comparing the survival of sedated and nonsedated patients. We present a systematic review of literature on the clinical practice of palliative sedation to assess the effect, if any, on survival.

METHODS

A systematic review of literature published between January 1980 and December 2010 was performed using MEDLINE and EMBASE databases. Search terms included palliative sedation, terminal sedation, refractory symptoms, cancer, neoplasm, palliative care, terminally ill, end-of-life care, and survival. A manual search of the bibliographies of electronically identified articles was also performed.

RESULTS

Eleven published articles were identified describing 1,807 consecutive patients in 10 retrospective or prospective nonrandomized studies, 621 (34.4%) of whom were sedated. One case-control study was excluded from prevalence analysis. The most frequent reason for sedation was delirium in the terminal stages of illness (median, 57.1%; range, 13.8% to 91.3%). Benzodiazepines were the most common drug category prescribed. Comparing survival of sedated and nonsedated patients, the sedation approach was not shown to be associated with worse survival.

CONCLUSION

Even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer. In this setting, palliative sedation is a medical intervention that must be considered as part of a continuum of palliative care.

A survey of the sedation practice of Portuguese palliative care teams

AIM

The purpose of this study is to study the practice of sedation by Portuguese palliative care teams.

METHODS

The teams included on the website of the Portuguese Association for Palliative Care were invited to participate. Data from all the patients sedated between April and June 2010 were recorded. Sedation was defined as the intentional administration of sedative drugs for symptom control, except insomnia, independently of the consciousness level reached.

RESULTS

Of the 19 teams invited only 4 actually participated. During the study period, 181 patients were treated: 171 (94 %) were cancer patients and 10 non-cancer patients. Twenty-seven (16 %) patients were sedated: 13 intermittently, 11 continuously, and 3 intermittently at first then continuously. The rate of sedation varied substantially among the teams. Delirium was the most frequent reason for sedation. Midazolam was the drug used in most cases. In 21 cases of sedation, the decision was made unilaterally by the professionals; in 16 (76 %) of those, the situation was deemed to be emergent. From the patients on continuous sedation, 9 (64 %) patients maintained oxygen, 13 (93 %) hydration, and 6 (43 %) nutrition. Two patients who had undergone intermittent sedation were discharged home and one was transferred to another institution; the reason for sedation in the three cases was delirium.

CONCLUSION

There is a substantial variation in the sedation rate among the teams. One of the most important aspects was the decision-making process which should be object of reflection and discussion in the teams.

[Principle of double effect and sedation for intractable distress: reflexion on survival in sedated patients]

The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. Studies conducted between 1990 and 2009 fail to show that the death of patients undergoing sedation for intractable distress is hastened. Some authors conclude that sedation does not hasten death and claim that principle of double effect is unnecessary in this debate. In our view, caution is required in the interpretation of studies results and absence of evidence of sedation effects on survival cannot be considered as an evidence of absence of sedation effects on survival. Furthermore, we consider obtaining a definitive answer as impossible in the future, as the required cannot be conducted for ethical reasons. Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.

Role of Haloperidol in Palliative Medicine

Haloperidol is a butyrophenone neuroleptic agent characterized as a high-affinity dopamine antagonist, originally used for the treatment of schizophrenia. Awareness of the role dopamine plays in many symptoms in palliative care, such as nausea, vomiting, and delirium, has led to the use of dopamine antagonists such as haloperidol for the treatment of these symptoms in the palliative care setting. Listed as 1 of the 25 important drugs in palliative care, haloperidol can be administered by multiple routes and can be given without dose alteration in the setting of both renal and hepatic insufficiency. Haloperidol is extensively metabolized in the liver, with CYP3A4 the chief cytochrome oxidase responsible for metabolism. This article will review the pharmacology, pharmacokinetics, and current uses of haloperidol in palliative medicine. There will be an examination of the evidence base for the use of haloperidol in palliative medicine.

Palliative sedation at the end of life at a tertiary cancer center

PURPOSE

The aim of this study was to describe the use of palliative sedation (PS) its indications and outcomes in patients followed up till death by an inpatient palliative care consult team (PCCT) at a tertiary cancer center.

METHODS

All patients referred for 5 years to the PCCT and followed up till death were eligible for the study. Both PCCT recordings and hospital charts were reviewed and a codified assessment was performed.

RESULTS

Over a total of 2,033 consecutive consults, 129 patients died during admission and were eligible. Eighty-three had the indication to PS, 4% of all consults (95% confidence interval [95%CI], 3% to 5%) and 64% of eligible patients (95%CI, 56% to 73%). PS was more frequently indicated in males and in patients with recurrent dyspnea and recurrent agitation, while it was less frequently indicated in older people and in patients with cerebral metastases and recurrent drowsiness. The most frequent indications to PS were dyspnea (37%) and delirium (31%) alone or combined with other symptoms. PS was successfully achieved in 69 patients; the drugs most frequently used for PS were midazolam (46%), haloperidol (35%), and chlorpromazine (32%) and opioid dose escalation was higher in sedated patients (P < 0.01).

CONCLUSIONS

PS is an important intervention in the management of terminal disease by a consulting palliative care team. Improved collaboration and communication between the hospital staff and the PCCT should be offered to meet patients' needs when PS is required.

The Attitudes of Indian Palliative-care Nurses and Physicians to Pain Control and Palliative Sedation

Aim:

We wanted to assess Indian palliative-care nurses and physicians’ attitudes toward pain control and palliative sedation.

Materials and Methods:

From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programs in New Delhi, using a semi-structured questionnaire, and following grounded-theory methodology (Glaser and Strauss).

Results:

The interviewees did not consider administration of painkillers in large doses an ethical problem, provided the pain killers are properly titrated. Mild palliative sedation was considered acceptable. The interviewees disagreed whether palliative sedation can also be deep and continuous. Arguments mentioned against deep continuous palliative sedation were the conviction that it may cause unacceptable side effects, and impedes basic daily activities and social contacts. A few interviewees said that palliative sedation may hasten death.

Conclusion:

Due to fears and doubts regarding deep continuous palliative sedation, it may sometimes be too easily discarded as a treatment option for refractory symptoms.

Continuous deep sedation until death in Belgium: a survey among nurses

CONTEXT

Continuous deep sedation (CDS) is a subject of important debate, but until now nurses have rarely been questioned about their involvement and perceptions.

OBJECTIVES

To study the communication process between nurses and patients, relatives, or physicians before starting CDS, and how nurses perceive this end-of-life practice.

METHODS

In 2007, we surveyed 1678 nurses in Flanders, Belgium, who, in an earlier survey, had reported caring for one or more patients who received an end-of-life decision within the previous year. Nurses were surveyed about their most recent case.

RESULTS

The response rate was 75.8%: 250 nurses reported a case of CDS (64.4% hospital, 18.4% home, and 17.2% nursing home). In, respectively, 25.8% and 75.4%, the patient and relatives had communicated with the nurse about the CDS. In 17.6%, there was no communication between the nurse and the physician about the CDS; in 29.1%, the physician and nurse only exchanged information; and in 23.4%, they made the decision jointly. Making the decision jointly was associated with a more positive evaluation of the cooperation with the physician (adjusted odds ratio 10.9 and 95% confidence interval 3.0, 39.2). Nurses perceived CDS as partly intended to hasten death partially in 48.4% and explicitly in 28.4% of cases, estimating possible or certain life shortening in 95.6%.

CONCLUSION

Nurses in different health care settings are often involved in communication about CDS. They see it mainly as a practice intended to hasten death, with a life-shortening effect; guidelines should recommend clear discussions between caregivers in which the physician states the purpose and estimated effect of the decision.

Development and validation of a modified version of the Edmonton Symptom Assessment Scale in a Flemish palliative care population

Palliative cancer patients are faced with multiple symptoms that threaten their quality of life. To manage these symptoms, a reliable and valid way of registration is crucial. In this study, the Edmonton Symptom Assessment Scale (ESAS) has been translated, modified, and tested on content, face, criterion, construct validity, and internal consistency for patients admitted to Flemish palliative care units. These aspects are tested in a descriptive, comparative, longitudinal study based on 3 convenience samples. The first consisted of 8 palliative care experts. The second sample checked the face validity and consisted of 4 patients, 5 family members, and 5 nurses. The last sample involved 23 patients admitted to 3 Flemish palliative care units. Heedful of the "new-wave" vision on validity, the translated and altered ESAS seemed a suitable instrument for the symptom assessment of patients with cancer admitted to a palliative care unit.

Palliative sedation, not slow euthanasia: a prospective, longitudinal study of sedation in Flemish palliative care units

CONTEXT

Palliative sedation remains a much debated and controversial issue. The limited literature on the topic often fails to answer ethical questions concerning this practice.

OBJECTIVES

The aim of this study was to describe the characteristics of patients who are being sedated for refractory symptoms in palliative care units (PCUs) from the time of admission until the day of death.

METHODS

A prospective, longitudinal, descriptive design was used to assess data in eight PCUs. The total sample consisted of 266 patients. Information on demographics, medication, food and fluid intake, decision making, level of consciousness, and symptom experience were gathered by nurses and researchers three times a week. If patients received palliative sedation, extra information was gathered.

RESULTS

Of all included patients (n=266), 7.5% received palliative sedation. Sedation started, on average, 2.5 days before death and for half of these patients, the form of sedation changed over time. At the start of sedation, patients were in the end stage of their illness and needed total care. Patients were fully conscious and had very limited oral food or fluid intake. Only three patients received artificial fluids at the start of sedation. Patients reported, on average, two refractory symptoms, the most important ones being pain, fatigue, depression, drowsiness, and loss of feeling of well-being. In all cases, the patient gave consent to start palliative sedation because of increased suffering.

CONCLUSION

This study revealed that palliative sedation is only administered in exceptional cases where refractory suffering is evident and for those patients who are close to the ends of their lives. Moreover, this study supports the argument that palliative sedation has no life-shortening effect.