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Ferraz-Gonçalves JA, Flores A, Silva AA, Simões A, Pais C, Melo C, Pirra D, Coelho D, Conde L, Real L, Feio M, Barbosa M, Martins MDL, Areias M, Muñoz-Romero R, Ferreira RC, Freitas S. Continuous Sedation in Palliative Care in Portugal: A Prospective Multicentric Study. J Palliat Care 2024:8258597241256874. [PMID: 38794900 DOI: 10.1177/08258597241256874] [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: 05/26/2024]
Abstract
Objective: This study aimed to survey the practice of palliative sedation in Portugal, where data on this subject were lacking. Methods: This was a prospective multicentric study that included all patients admitted to each team that agreed to participate. Patients were followed until death, discharge, or after 3 months of follow-up. Results: The study included 8 teams: 4 as palliative care units (PCU), 1 as a hospital palliative care team (HPCT), 2 as home care (HC), and 1 as HPCT and HC. Of the 361 patients enrolled, 52% were male, the median age was 76 years, and 285 (79%) had cancer. Continuous sedation was undergone by 49 (14%) patients: 26 (53%) were male, and the median age was 76. Most patients, 46 (94%), had an oncological diagnosis. Only in a minority of cases, the family, 16 (33%), or the patient, 5 (10%), participated in the decision to sedate. Delirium was the most frequent symptom leading to sedation. The medication most used was midazolam (65%). In the multivariable analysis, only age and the combined score were independently associated with sedation; patients <76 years and those with higher levels of suffering had a higher probability of being sedated. Conclusions: The practice of continuous palliative sedation in Portugal is within the range reported in other studies. One particularly relevant point was the low participation of patients and their families in the decision-making process. Each team must have a deep discussion on this aspect.
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Affiliation(s)
| | - Alice Flores
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Macedo de Cavaleiros, Portugal
| | - Ana Abreu Silva
- Department of Palliative Care, Serviço de Saúde da Região Autónoma da Madeira (SESARAM), Funchal, Portugal
| | - Ana Simões
- Hospital Palliative Care Team and Home Care Unit, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Carmen Pais
- Clinical Academic Center of Trás-os-Montes and Alto Douro - Professor Doctor Nuno Grande - CACTMAD, Vila Real, Portugal
| | - Clarisse Melo
- Community Team of Palliative Care, ACES Lisboa Ocidental e Oeiras, Lisbon, Portugal
| | - Diana Pirra
- Department of Palliative Care, Hospital Santa Luzia, Elvas, Portugal
| | - Dora Coelho
- Department of Palliative Care, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Lília Conde
- Community Team of Palliative Care, Maia/Valongo, Portugal
| | - Lorena Real
- Department of Palliative Care, Hospital Santa Luzia, Elvas, Portugal
| | - Madalena Feio
- Hospital Palliative Care Team and Home Care Unit, Portuguese Oncology Institute of Lisbon, Lisbon, Portugal
| | - Manuel Barbosa
- Community Team of Palliative Care, Maia/Valongo, Portugal
| | - Maria de Lurdes Martins
- Clinical Academic Center of Trás-os-Montes and Alto Douro - Professor Doctor Nuno Grande - CACTMAD, Vila Real, Portugal
| | - Marlene Areias
- Department of Palliative Care, Unidade Local de Saúde do Nordeste, Macedo de Cavaleiros, Portugal
| | - Rafael Muñoz-Romero
- Department of Palliative Care, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | - Rita Cunha Ferreira
- Community Team of Palliative Care, ACES Lisboa Ocidental e Oeiras, Lisbon, Portugal
| | - Susete Freitas
- Department of Palliative Care, Serviço de Saúde da Região Autónoma da Madeira (SESARAM), Funchal, Portugal
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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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Rodrigues P, Ostyn J, Mroz S, Ronsse A, Menten J, Gastmans C. Ethics of sedation for existential suffering: palliative medicine physician perceptions - qualitative study. BMJ Support Palliat Care 2022; 13:209-217. [PMID: 35418444 DOI: 10.1136/bmjspcare-2021-003395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Palliative sedation for existential suffering (PS-ES) is considered a controversial practice to control refractory suffering at the end of life. This study aims to explore Belgian palliative care physicians' perceptions regarding the ethics of PS-ES. METHODS This nationwide qualitative study follows a Grounded Theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 23 Belgian hospitals and hospices (Flanders, Brussels, Wallonia). We analysed the data using the Qualitative Analysis Guide Of Leuven and we followed the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS The data revealed that Belgian palliative care physicians have difficulty characterising ES and distinguishing it from other types of suffering. They express mixed attitudes towards PS-ES and employ a wide range of ethical arguments in favour and against it, which are mainly linked to the four principles of biomedical ethics. CONCLUSION Since there is a lack of consensus among Belgian palliative care physicians about PS-ES, further research is needed to clarify their attitudes. A better understanding of physicians' underlying presuppositions can provide more insight into their perceptions of ES and PS-ES and provide further insight for establishing good practices in ES management at the end of life.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sarah Mroz
- Vrije Universiteit Brussel, Brussel, Belgium
| | - Axelle Ronsse
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan Menten
- Radiation-Oncology and Palliatiev Care, UZ Gasthuisberg, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Emmerich N, Gordijn B. Ethics of crisis sedation: questions of performance and consent. JOURNAL OF MEDICAL ETHICS 2019; 45:339-345. [PMID: 31005858 DOI: 10.1136/medethics-2018-105285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 06/09/2023]
Abstract
This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term 'crisis sedation.' We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.
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Affiliation(s)
- Nathan Emmerich
- School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- Institute of Ethics, Dublin City University, Dublin, Ireland
| | - Bert Gordijn
- Institute of Ethics, Dublin City University, Dublin, Ireland
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Barreth A, Fainsinger R, Oneschuk D, Pritchard Z. The Challenge of Communicating Intent of Sedation in Advanced Illness. J Palliat Care 2019. [DOI: 10.1177/082585970301900313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Angela Barreth
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Robin Fainsinger
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Doreen Oneschuk
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
| | - Zinia Pritchard
- Tertiary Palliative Care Program, Grey Nuns Community Hospital, Edmonton, Canada
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Ciancio AL, Mirza RM, Ciancio AA, Klinger CA. The Use of Palliative Sedation to Treat Existential Suffering: A Scoping Review on Practices, Ethical Considerations, and Guidelines. J Palliat Care 2019; 35:13-20. [DOI: 10.1177/0825859719827585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context: Though palliative sedation has been recognized as an acceptable practice in Canada for many years now, there is a lack of clinical research and guidelines pertaining to its use as a treatment of existential refractory symptoms in the terminally ill. Objectives: This scoping review aimed to survey the literature surrounding palliative sedation and existential suffering and to inform research, policy, and practice. Methods: To address the main research question: Is palliative sedation an acceptable intervention to treat existential refractory symptoms in adults aged 65 and older? a scoping review following Arksey and O’Malley’s framework was performed, spanning electronic databases of the peer reviewed and grey literature. Articles were screened for inclusion, and a thematic content analysis allowed for a summary of key findings. Results: Out of 427 search results, 71 full text articles were obtained, 20 of which were included. Out of these articles, four themes were identified as key findings. These included: (1) Ethical considerations; (2) The role of the health care provider; looking specifically at the impact on nurses; (3) The need for multidisciplinary care teams; and (4) Existential suffering’s connection to religiosity and spirituality. Conclusion: Palliative sedation to treat existential refractory symptoms was labelled a controversial practice. A shortage of evidence-based resources limits the current literature’s ability to inform policy and clinical practice. There is a need for both qualitative and quantitative multi-center research so health care professionals and regional-level institutions have firm roots to establish proper policy and practice.
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Affiliation(s)
- Allysa L. Ciancio
- Health Studies Program, University of Toronto, Toronto, Ontario, Canada
| | - Raza M. Mirza
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada
| | - Amy A. Ciancio
- Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Christopher A. Klinger
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada
- Translational Research Program, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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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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8
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Voeuk A, Nekolaichuk C, Fainsinger R, Huot A. Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views. J Palliat Care 2018; 32:26-33. [PMID: 28662627 DOI: 10.1177/0825859717711301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory. OBJECTIVES The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress. METHODS A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians. RESULTS Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone. CONCLUSION Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.
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Affiliation(s)
- Anna Voeuk
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl Nekolaichuk
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,2 Covenant Health Palliative Institute, Edmonton, Alberta, Canada
| | - Robin Fainsinger
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,2 Covenant Health Palliative Institute, Edmonton, Alberta, Canada
| | - Ann Huot
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,3 Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
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Rodrigues P, Crokaert J, Gastmans C. Palliative Sedation for Existential Suffering: A Systematic Review of Argument-Based Ethics Literature. J Pain Symptom Manage 2018; 55:1577-1590. [PMID: 29382541 DOI: 10.1016/j.jpainsymman.2018.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
CONTEXT Although unanimity exists on using palliative sedation (PS) for controlling refractory physical suffering in end-of-life situations, using it for controlling refractory existential suffering (PS-ES) is controversial. Complicating the debate is that definitions and terminology for existential suffering are unclear, ambiguous, and imprecise, leading to a lack of consensus for clinical practice. OBJECTIVES To systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on PS-ES. METHODS We conducted a systematic search of the argument-based bioethics literature in PubMed, CINAHL, Embase®, The Philosopher's Index, PsycINFO®, PsycARTICLES®, Scopus, ScienceDirect, Web of Science, Pascal-Francis, and Cairn. We included articles published in peer-reviewed journals till December 31, 2016, written in English or French, which focused on ethical arguments related to PS-ES. We used Peer Review of Electronic Search Strategies protocol, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and The Qualitative Analysis Guide of Leuven for data extraction and synthesis of themes. RESULTS We identified 18 articles that met the inclusion criteria. Our analysis revealed mind-body dualism, existential suffering, refractoriness, terminal condition, and imminent death as relevant concepts in the ethical debate on PS-ES. The ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate. CONCLUSION There is a clear need to better define the terminology used in discussions of PS-ES and to ground ethical arguments in a more effective way. Anthropological presuppositions such as mind-body dualism underpin the debate and need to be more clearly elucidated using an interdisciplinary approach.
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Affiliation(s)
- Paulo Rodrigues
- Université Catholique de Lille, ETHICS EA7446, Centre for Medical Ethics, Lille, France; Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium; Université Catholique de Louvain, Research Institute Religions, Spirituality, Cultures, Societies (RSCS), Louvain-la-Neuve, Belgium.
| | - Jasper Crokaert
- Université Catholique de Louvain, Faculty of Medicine, Louvain-la-Neuve, Belgium
| | - Chris Gastmans
- Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium
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van Deijck RH, Hasselaar JG, Krijnsen PJ, Gloudemans AJ, Verhagen SC, Vissers KC, Koopmans RT. The Practice of Continuous Palliative Sedation in Long-Term Care for Frail Patients with Existential Suffering. J Palliat Care 2017; 31:141-9. [DOI: 10.1177/082585971503100303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Some guidelines and recommendations identify existential suffering as a potential refractory symptom for which continuous palliative sedation (CPS) can be administered under certain conditions. However, there has been little research on the characteristics of patients with existential suffering treated with CPS and the degree to which the preconditions are fulfilled. The aim of this study was to provide insight into this specific indication for CPS. Questionnaires were sent to nursing home physicians in the Netherlands, who described 314 patients. Existential suffering was a refractory symptom in 83 of the patients. For most of the patients with refractory existential suffering, other refractory symptoms were also reported, and life expectancy was seven days or less; informed consent for initiating CPS had been obtained in all cases. Consultation and intermittent sedation before the start of CPS were far less frequently reported than one would expect based on the guidelines. Multivariate analysis showed that being male, having previously requested euthanasia, having a nervous system disease, or having an other diagnosis were positively correlated with the administration of CPS for existential suffering. We conclude that more attention should be paid to the suggested preconditions and to the presence of existential suffering in male patients or patients with a nervous system disease.
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Affiliation(s)
| | - Jeroen G.J. Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Petrus J.C. Krijnsen
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | | | - Stans C.A.H.H.V.M. Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kris C.P. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, Netherlands; and De Waalboog, Specialized Geriatric Care Centre Joachim en Anna, Nijmegen, Netherlands
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Abstract
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.
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15
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Smyre CL, Yoon JD, Rasinski KA, Curlin FA. Limits and responsibilities of physicians addressing spiritual suffering in terminally ill patients. J Pain Symptom Manage 2015; 49:562-9. [PMID: 25131887 DOI: 10.1016/j.jpainsymman.2014.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 06/17/2014] [Accepted: 06/26/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT Many patients experience spiritual suffering that complicates their physical suffering at the end of life. It remains unclear what physicians' perceived responsibilities are for responding to patients' spiritual suffering. OBJECTIVES To investigate U.S. physician opinions about the impact patients' unresolved spiritual struggles have on their physical pain, physicians' responsibilities for treating patients' spiritual suffering compared with patients' physical pain, and the number of patients in the past 12 months whose suffering the physician was unable to relieve to an acceptable point. METHODS The study was based on a mailed survey to 2016 practicing U.S. physicians from clinical specialties that care for significant numbers of dying patients. RESULTS Of 1878 eligible physicians, 1156 (62%) responded. Most physicians agreed that patients with unresolved spiritual struggles tend to have worse physical pain (81%) and that physicians should seek to relieve patients' spiritual suffering just as much as patients' physical pain (88%). Compared with physicians who strongly disagreed that physicians should seek to relieve patients' spiritual suffering just as much as patients' physical pain, those who strongly agreed were less likely to report being unable to relieve patients' suffering to a point the physician found acceptable (27% vs. 54% reported three or more such patients in the previous 12 months, adjusted odds ratio [95% CI] = 0.3 [0.1, 0.8]). CONCLUSION Most physicians believe that spiritual suffering tends to intensify physical pain and that physicians should seek to relieve such suffering. Physicians who believe they should address spiritual suffering just as much as physical pain report more success in relieving patient's suffering.
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Affiliation(s)
- Chris L Smyre
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA.
| | - John D Yoon
- Sections of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Kenneth A Rasinski
- General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Trent Center for Bioethics, Humanities & History of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Portnoy A, Rana P, Zimmermann C, Rodin G. The Use of Palliative Sedation to Treat Existential Suffering: A Reconsideration. PHILOSOPHY AND MEDICINE 2015. [DOI: 10.1007/978-94-017-9106-9_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Cherny N. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014; 25 Suppl 3:iii143-52. [DOI: 10.1093/annonc/mdu238] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bruinsma SM, Brown J, van der Heide A, Deliens L, Anquinet L, Payne SA, Seymour JE, Rietjens JAC. Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries. Support Care Cancer 2014; 22:3243-52. [PMID: 25022759 DOI: 10.1007/s00520-014-2344-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/29/2014] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- S M Bruinsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Papavasiliou E, Payne S, Brearley S. Current debates on end-of-life sedation: an international expert elicitation study. Support Care Cancer 2014; 22:2141-9. [DOI: 10.1007/s00520-014-2200-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/04/2014] [Indexed: 11/28/2022]
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Anquinet L, Rietjens J, van der Heide A, Bruinsma S, Janssens R, Deliens L, Addington-Hall J, Smithson WH, Seymour J. Physicians' experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life. Psychooncology 2013; 23:539-46. [PMID: 24307235 PMCID: PMC4282582 DOI: 10.1002/pon.3450] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 09/07/2013] [Accepted: 10/21/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The use of continuous sedation until death for terminally ill cancer patients with unbearable and untreatable psychological and existential suffering remains controversial, and little in-depth insight exists into the circumstances in which physicians resort to it. METHODS Our study was conducted in Belgium, the Netherlands, and the UK in hospitals, PCUs/hospices, and at home. We held interviews with 35 physicians most involved in the care of cancer patients who had psychological and existential suffering and had been continuously sedated until death. RESULTS In the studied countries, three groups of patients were distinguished regarding the origin of their psychological and existential suffering. The first group had preexisting psychological problems before they became ill, the second developed psychological and existential suffering during their disease trajectory, and the third presented psychological symptoms that were characteristic of their disease. Before they resorted to the use of sedation, physicians reported that they had considered an array of pharmacological and psychological interventions that were ineffective or inappropriate to relieve this suffering. Necessary conditions for using sedation in this context were for most physicians the presence of refractory symptoms, a short life expectancy, and an explicit patient request for sedation. CONCLUSIONS Physicians in our study used continuous sedation until death in the context of psychological and existential suffering after considering several pharmacological and psychological interventions. Further research and debate are needed on how and by whom this suffering at the end of life should be best treated, taking into account patients' individual preferences.
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Affiliation(s)
- Livia Anquinet
- VUB-UGent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
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Putman MS, Yoon JD, Rasinski KA, Curlin FA. Intentional sedation to unconsciousness at the end of life: findings from a national physician survey. J Pain Symptom Manage 2013; 46:326-34. [PMID: 23219679 DOI: 10.1016/j.jpainsymman.2012.09.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/06/2012] [Accepted: 09/19/2012] [Indexed: 11/25/2022]
Abstract
CONTEXT The terms "palliative sedation" and "terminal sedation" have been used to refer to both proportionate palliative sedation, in which unconsciousness is a foreseen but unintended side effect, and palliative sedation to unconsciousness, in which physicians aim to make their patients unconscious until death. It has not been clear to what extent palliative sedation to unconsciousness is accepted and practiced by U.S. physicians. OBJECTIVES To investigate U.S. physician acceptance and practice of palliative sedation to unconsciousness and to identify predictors of that practice. METHODS In 2010, a survey was mailed to 2016 practicing U.S. physicians. Criterion measures included self-reported practice of palliative sedation to unconsciousness until death and physician endorsement of such sedation for a hypothetical patient with existential suffering at the end of life. RESULTS Of the 1880 eligible physicians, 1156 responded to the survey (62%). One in ten (141/1156) physicians had sedated a patient in the previous 12 months with the specific intention of making the patient unconscious until death, and two of three physicians opposed sedation to unconsciousness for existential suffering, both in principle (68%, n = 773) and in the case of a hypothetical dying patient (72%, n = 831). Eighty-five percent (n = 973) of physicians agreed that unconsciousness is an acceptable side effect of palliative sedation but should not be directly intended. CONCLUSION Although there is widespread support among U.S. physicians for proportionate palliative sedation, intentionally sedating dying patients to unconsciousness until death is neither the norm in clinical practice nor broadly supported for the treatment of primarily existential suffering.
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Affiliation(s)
- Michael S Putman
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA
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Rys S, Deschepper R, Deliens L, Mortier F, Bilsen J. Justifying continuous sedation until death: A focus group study in nursing homes in Flanders, Belgium. Geriatr Nurs 2013; 34:105-11. [DOI: 10.1016/j.gerinurse.2012.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/18/2012] [Accepted: 10/22/2012] [Indexed: 11/17/2022]
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Dean MM, Cellarius V, Henry B, Oneschuk D, Librach (Canadian Society of Pallia SL. Framework for Continuous Palliative Sedation Therapy in Canada. J Palliat Med 2012; 15:870-9. [DOI: 10.1089/jpm.2011.0498] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mervyn M. Dean
- Palliative Care, Western Memorial Regional Hospital, Corner Brook, Newfoundland and Labrador, Canada
| | - Victor Cellarius
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Blair Henry
- Ethics Centre, Sunnybrook Health Sciences Centre, Department of Family and Community Medicine, University of Toronto, University of Toronto, Toronto, Ontario, Canada
- Joint Centre for Bioethics, University of Toronto, Ontario, Canada
| | - Doreen Oneschuk
- Edmonton Regional Palliative Care Program, Grey Nuns Hospital, Edmonton, Alberta, Canada
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A survey of the sedation practice of Portuguese palliative care teams. Support Care Cancer 2012; 20:3123-7. [PMID: 22447339 DOI: 10.1007/s00520-012-1442-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 03/12/2012] [Indexed: 10/28/2022]
Abstract
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.
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Abstract
Medical principles of pain treatment are generally in line with the judicial principles. To relieve pain is one of the fundamentals of medicine and this has also been acknowledged by the Federal Court in Germany. It is criminal bodily harm, when a physician denies a possible pain treatment. Whereas courts clearly see an obligation to basic and continuing education in pain diagnosis and therapy, pain is still not represented in the German licensing regulations for physicians. Only palliative medicine has been added to the obligatory curriculum. Very similar pain is not mandatory in many clinical disciplines leaving physicians without the needed knowledge to treat pain. The need for interdisciplinary treatment is not yet acknowledged sufficiently, although meanwhile chronic pain is regarded as a bio-psycho-social illness.Since 2009 the advance directive is regulated by law. However, still many physicians are unaware that not only the position of the patient but also of the relatives have been strengthened. In 2010 the Federal Court has pronounced a judgment allowing "passive euthanasia" in certain conditions but prohibiting any active handling even in line with the patient's will. This is also in line with the European Human Rights Convention. The judicial unpunished assisted suicide has provoked an ethical discussion within the medical profession. However, what is not illegal is not automatically accepted as ethical handling for physicians. Palliative medicine is at least one alternative in this discussion.
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Sedierung in der Palliativmedizin*: Leitlinie für den Einsatz sedierender Maßnahmen in der Palliativversorgung. Schmerz 2010; 24:342-54. [DOI: 10.1007/s00482-010-0948-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23:581-93. [PMID: 19858355 DOI: 10.1177/0269216309107024] [Citation(s) in RCA: 407] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.
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Affiliation(s)
- Nathan I Cherny
- Shaare Zedek Medical Center, Department of Oncology, Jerusalem, Israel.
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When cancer symptoms cannot be controlled: the role of palliative sedation. Curr Opin Support Palliat Care 2009; 3:14-23. [PMID: 19365157 DOI: 10.1097/spc.0b013e3283260628] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Palliative sedation, the intentional lowering of consciousness for refractory and unbearable distress, has been much discussed during the last decade. In recent years, much research has been published about this subject that will be discussed in this review. The review concentrates on: a brief overview of the main developments during the last decade, an exploration of current debate regarding ethical dilemmas, the development of clinical guidelines, and the application of palliative sedation. RECENT FINDINGS Main findings are that palliative sedation is mostly described in retrospective studies and that the terminology palliative sedation in now common in the majority of the studies. In addition, life-shortening effects for palliative sedation are scarcely reported, although not absent. A number of guidelines have been developed and published, although systematic implementation needs more attention. Consequently, palliative sedation has become more clearly positioned as a medical treatment, to be distinguished from active life shortening. SUMMARY Caregivers should apply palliative sedation proportionally, guided by the symptoms of the patient without striving for deep coma and without motives for life shortening. Clinical and multidisciplinary assessment of refractory symptoms is recommended as is patient monitoring during sedation. Future research should concentrate on proportional sedation rather than continuous deep sedation exclusively, preferably in a prospective design.
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Maltoni M, Pittureri C, Scarpi E, Piccinini L, Martini F, Turci P, Montanari L, Nanni O, Amadori D. Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol 2009; 20:1163-9. [DOI: 10.1093/annonc/mdp048] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Schuman-Olivier Z, Brendel DH, Forstein M, Price BH. The use of palliative sedation for existential distress: a psychiatric perspective. Harv Rev Psychiatry 2009; 16:339-51. [PMID: 19085388 DOI: 10.1080/10673220802576917] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision-making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.
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Affiliation(s)
- Zev Schuman-Olivier
- Department of Psychiatry, Harvard Medical School, Cambridge Health Alliance, Cambridge, MA 02139, USA.
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de Graeff A, Dean M. Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards. J Palliat Med 2007; 10:67-85. [PMID: 17298256 DOI: 10.1089/jpm.2006.0139] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards. METHODS A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions. RESULTS PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented. CONCLUSION When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.
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Affiliation(s)
- Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, F.02.126 Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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33
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Cherny NI. Sedation for the care of patients with advanced cancer. ACTA ACUST UNITED AC 2006; 3:492-500. [PMID: 16955088 DOI: 10.1038/ncponc0583] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2006] [Accepted: 05/02/2006] [Indexed: 11/09/2022]
Abstract
Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.
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Affiliation(s)
- Nathan I Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel.
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Affiliation(s)
- Michael E Salacz
- Division of Neoplastic Diseases, Medical College of Wisconsin, Milwakee, Wisconsin 53226, USA
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35
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Rousseau PC. Palliative Sedation in Terminally Ill Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 550:263-7. [PMID: 15053444 DOI: 10.1007/978-0-306-48526-8_24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Braun TC, Hagen NA, Clark T. Development of a clinical practice guideline for palliative sedation. J Palliat Med 2003; 6:345-50. [PMID: 14509479 DOI: 10.1089/109662103322144655] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Palliative sedation is an effective symptom control strategy for patients who suffer from intractable symptoms at the end of life. Evidence suggests that the use of this practice varies considerably. In order to minimize variation in the practice of palliative sedation within our health region, we developed a clinical practice guideline (CPG) for the use of palliative sedation. Using available evidence from the literature, a five step process was employed to develop the CPG: (1) a working group was charged with the mandate to develop a draft guideline; (2) a working definition for palliative sedation was developed; (3) criteria for use of sedation were determined; (4) critical steps to be taken prior to initiation of sedation were defined; and (5) the CPG was reviewed by local stakeholders. Feedback from the wider group of stakeholders was used to arrive at the final CPG, which subsequently received approval from the local Medical Advisory Board. The process used to develop the CPG served to develop consensus within the local community of palliative care clinicians regarding the practice of palliative sedation. Subsequently, the CPG was used as a tool for educating other health care providers.
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Affiliation(s)
- Ted C Braun
- Calgary Regional Palliative & Hospice Care Service, Calgary, Alberta, Canada.
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Morita T, Hirai K, Akechi T, Uchitomi Y. Similarity and difference among standard medical care, palliative sedation therapy, and euthanasia: a multidimensional scaling analysis on physicians' and the general population's opinions. J Pain Symptom Manage 2003; 25:357-62. [PMID: 12691687 DOI: 10.1016/s0885-3924(02)00684-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
There is a strong controversy about the differences among standard medical care, palliative sedation therapy, and euthanasia in recent medical literature. To investigate the similarities and differences among these medical treatments, a secondary analysis of two previous surveys was performed. In those surveys, Japanese physicians and the general population were asked to identify their treatment recommendations or preferences for intolerable and refractory distress in the terminal stage. The options were standard medical care without intentional sedation, mild sedation, intermittent deep sedation, continuous deep sedation, and physician-assisted suicide (PAS)/euthanasia. Multidimensional scaling analysis mapped their responses. The physician responses were clustered into 3 groups: 1) standard medical care, 2) palliative sedation therapy including mild, intermittent deep, continuous deep sedation, and 3) PAS/euthanasia. The general population's responses were classified into 3 subgroups: 1) standard medical care, 2) mild and intermittent deep sedation, and 3) a group including continuous deep sedation and PAS/euthanasia. Physicians placed continuous deep sedation closer to mild and intermittent sedation, while the general population mapped it closer to PAS/euthanasia. In conclusion, physicians and general population can generally differentiate the three approaches--standard medical care, palliative sedation therapy, and PAS/euthanasia. We recommend that mild and intermittent deep sedation should be differentiated from standard medical care, and that continuous deep sedation should be dealt with separately from other types of sedation. Clear definitions of palliative sedation therapy will contribute to quality discussion.
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Affiliation(s)
- Tatsuya Morita
- Seirei Hospice, Seirei Mikatabara Hospital, 3453 Mikatabara-cho, Hamamatsu, Shizuoka 433-8558, Japan
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39
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Morita T, Tsuneto S, Shima Y. Definition of sedation for symptom relief: a systematic literature review and a proposal of operational criteria. J Pain Symptom Manage 2002; 24:447-53. [PMID: 12505214 DOI: 10.1016/s0885-3924(02)00499-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although sedation for symptom relief in terminally ill patients has been the focus of recent medical studies, the interpretation of research findings is difficult due to the confusing terminology. To clarify the agreements and inconsistencies in the definitions of sedation, a systematic review was performed. We searched the literature through MEDLINE from 1990 to July 2001. A total of 7 articles met the inclusion criteria. All studies included the use of sedative medications or the intention to reduce patient consciousness as an essential element of sedation. All but one study explicitly described that the primary aim of sedation was symptom palliation. Three definitions stated that target symptoms were severe, and 4 articles reported the refractory nature of the distress. On the other hand, there were marked inconsistencies in the definition of the degree of sedation, duration, pharmacological properties of medications used, target symptoms, and target populations. This review suggests that sedation includes two core factors: the presence of severe suffering refractory to standard palliative management, and the use of sedative medications with the primary aim to relieve distress. Thus, "palliative sedation therapy" can be defined as "the use of sedative medications to relieve intolerable and refractory distress by the reduction in patient consciousness." The marked inconsistencies in the definition of sedation should be considered to be subcategories of palliative sedation therapy, and we recommend that researchers define the degree of sedation, duration, pharmacological properties of medications, target symptoms, and target populations in future studies. This clarification of terminology will contribute to improving the accuracy and depth of sedation research.
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Affiliation(s)
- Tatsuya Morita
- Seirei Hospice, Seirei Mikatabara Hospital, 3453 Mika-tabara-cho, Hamamatsu, Shizuoka 433-8558, Japan
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Abstract
Treatment for patients who are dying from cancer and are suffering with physiologic and existential symptoms is an important and valuable skill for health care providers. However, the treatment for suffering at the end of life and the use of sedation for comfort often are misunderstood. The following is a discussion of the clinical skills and ethical considerations that health care providers should have when treating terminal patients with cancer.
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Affiliation(s)
- Olivia Walton
- Huntsman Cancer Institute, University of Utah, 2000 E. Circle of Hope, Salt Lake City, UT 84112, USA.
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Abstract
Managing delirium is of major importance in end-of-life care and frequently gives rise to controversies and to clinical and ethical dilemmas. These problems arise from a number of causes, including the sometimes-poor recognition or misdiagnosis of delirium despite its frequent occurrence. Delirium generates major symptomatic of distress for the patient, consequent stress for the patient's family, the potential to misinterpret delirium symptomatology, and behavioral management challenges for health care professionals. Paradoxically, delirium is potentially reversible in some episodes, but in many patients delirium presents a nonreversible terminal episode. Greater educational efforts are required to improve the recognition of delirium and lead to a better understanding of its impact in end-of-life care. Future research might focus on phenomenology, the development of low-burden instruments for assessment, communication strategies, and the family education regarding the manifestations of delirium. Further research is needed among patients with advanced cancer to establish a predictive model for reversibility that recognizes both baseline vulnerability factors and superimposed precipitating factors. Evidence-based guidelines should be developed to assist physicians in more appropriate use of sedation in the symptomatic management of delirium.
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Affiliation(s)
- Peter G Lawlor
- Department of Oncology, Division of Palliative Care Medicine, University of Alberta, Tertiary-level Palliative Care Unit, Grey Nuns Community Hospital, Edmonton, Alberta, Canada T6L 5X8.
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Abstract
Palliative care clinicians are faced with the challenge of managing a multitude of complex symptom combinations in patients for whom they care. Although many symptoms respond favourably to established protocols, others may remain refractory to such intervention. It is within the context of trying to manage such symptoms that the issue of palliative sedation therapy arises. The use of sedation in such circumstances is one that has prompted considerable debate in the palliative care literature. Discourse has been hampered, however, by a lack of consensus regarding the meaning and intent of palliative sedation therapy, when it should be used clinically and how it is to be achieved pharmacologically. There is a dearth of research examining the meanings ascribed to its use from the perspective of patients, families, and health-care providers. This article will provide an overview of these identified issues, and provide suggestions for ways in which palliative sedation therapy might further be examined and understood.
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Rousseau P. Existential suffering and palliative sedation: a brief commentary with a proposal for clinical guidelines. Am J Hosp Palliat Care 2001; 18:151-3. [PMID: 11406884 DOI: 10.1177/104990910101800303] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
The physician's main goal in caring for a dying person is to reduce suffering, including pain, physical symptoms, and emotional, psychosocial, and spiritual distress. In refractory and intractable cases, palliative sedation offers a compassionate and humane alternative to conscious and continual suffering, both for the patient and the patient's family. Without a doubt, further studies are necessary, particularly in cases of cognitive impairment, but palliative sedation offers a valuable and efficacious intervention for interminable suffering at the end of life.
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Affiliation(s)
- P Rousseau
- VA Medical Center, Phoenix, Ariz. 85310, USA.
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