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Fasse L, Roche N, Flahault C, Garrouste-Orgeas M, Ximenes M, Pages A, Evin A, Dauchy S, Scotte F, Le Provost JB, Blot F, Mateus C. The APSY-SED study: protocol of an observational, longitudinal, mixed methods and multicenter study exploring the psychological adjustment of relatives and healthcare providers of patients with cancer with continuous deep sedation until death. BMC Palliat Care 2022; 21:217. [PMID: 36464684 PMCID: PMC9720978 DOI: 10.1186/s12904-022-01106-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since 2016, France is the only country in the World where continuous deep sedation until death (CDSUD) is regulated by law. CDSUD serves as a response to refractory suffering in palliative situations where the patients' death is expected to occur in the following hours or days. Little is known on the psychological adjustment surrounding a CDSUD procedure for healthcare providers (HCPs) and relatives. Our study aims to gather qualitative and quantitative data on the specific processes behind the psychological adjustment of both relatives and HCPs, after the administration of CDSUD for patients with cancer. METHODS The APSY-SED study is a prospective, longitudinal, mixed-methods and multicenter study. Recruitment will involve any French-speaking adult cancer patient for who a CDSUD is discussed, their relatives and HCPs. We plan to include 150 patients, 150 relatives, and 50 HCPs. The evaluation criteria of this research are: 1/ Primary criterion: Psychological adjustment of relatives and HCPs 6 and 13 months after the death of the patient with cancer (psychological adjustment = intensity of anxiety, depression and grief reactions, CDSUD-related distress, job satisfaction, Professional Stress and Professional experience). Secondary criteria: a)occurrence of wish for a CDSUD in patients in palliative phase; b)occurrence of wish for hastened death in patients in palliative phase; c)potential predictors of adjustment assessed after the discussion concerning CDSUD as an option and before the setting of the CDSUD; d) Thematic analysis and narrative account of meaning-making process concerning the grief experience. DISCUSSION The APSY-SED study will be the first to investigate the psychological adjustment of HCPs and relatives in the context of a CDSUD procedure implemented according to French law. Gathering data on the grief process for relatives can help understand bereavement after CDSUD, and participate in the elaboration of specific tailored interventions to support HCPs and relatives. Empirical findings on CDSUD among patients with cancer in France could be compared with existing data in other countries and with results related to other medical fields where CDSUD is also conducted. TRIAL REGISTRATION This protocol received the National Registration Number: ID-RCB2021-A03042-39 on 14/12/2021.
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Affiliation(s)
- L Fasse
- DIOPP, Gustave Roussy Hospital, Villejuif, France.
- Institut de Psychologie Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, 71 avenue E. Vaillant, F-92100, Boulogne- Billancourt, France.
| | - N Roche
- DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - C Flahault
- DIOPP, Gustave Roussy Hospital, Villejuif, France
- Institut de Psychologie Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, 71 avenue E. Vaillant, F-92100, Boulogne- Billancourt, France
| | - M Garrouste-Orgeas
- IAME, INSERM, Université de Paris, F-75018, Paris, France
- Palliative Care unit, Reuilly Diaconesses Fondation, Rueil Malmaison, France
- Medical unit, French British Hospital, Levallois-Perret, France
| | - M Ximenes
- Maison Médicale Marie Galène, Bordeaux, France
| | - A Pages
- Biostatistical Unit, Gustave Roussy Hospital, Villejuif, France
| | - A Evin
- Palliative Care unit, CHU, Nantes, France
| | - S Dauchy
- DMU Psychiatry and Addictology, AP-HP.Centre, Université de Paris, Paris, France
| | - F Scotte
- DIOPP, Gustave Roussy Hospital, Villejuif, France
| | | | - F Blot
- DIOPP, Gustave Roussy Hospital, Villejuif, France
| | - C Mateus
- DIOPP, Gustave Roussy Hospital, Villejuif, France
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Hedman C, Rosso A, Häggström O, Nordén C, Fürst CJ, Schelin MEC. Sedation in specialized palliative care: A cross-sectional study. PLoS One 2022; 17:e0270483. [PMID: 35802571 PMCID: PMC9269455 DOI: 10.1371/journal.pone.0270483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Palliative sedation is used to relieve refractory symptoms and is part of clinical practice in Sweden. Yet we do not know how frequently this practice occurs, how decision-making takes place, or even which medications are preferentially used. Objectives To understand the current practice of palliative sedation in Sweden. Methods We conducted a retrospective cross-sectional medical record-based study. For 690 consecutive deceased patients from 11 of 12 specialized palliative care units in the southernmost region of Sweden who underwent palliative sedation during 2016, we collected data on whether the patient died during sedation and, for sedated patients, the decision-making process, medication used, and depth of sedation. Results Eight percent of patients were sedated. Almost all (94%) were given midazolam, sometimes in combination with propofol. The proportions of sedation were similar in the patient groups with and without cancer. The largest proportion of the sedated patients died in inpatient care, but 23% died at home, with specialized palliative home care. Among the patients with a decision to sedate, 42% died deeply unconscious, while for those without such a decision the corresponding figure was 16%. In only one case was there more than one physician involved in the decision to use palliative sedation. Conclusion 8% of patients in specialized palliative care received palliative sedation, which is lower than international measures but much increased compared to an earlier Swedish assessment. The level of consciousness achieved often did not correspond to the planned level; this, together with indications of a scattered decision process, shows a need for clear guidelines.
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Affiliation(s)
- Christel Hedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- R&D Department, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Aldana Rosso
- Division of Geriatric Medicine, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Ola Häggström
- Unit of Palliative Care Kristianstad, Region Skåne, Kristianstad, Sweden
| | | | - Carl Johan Fürst
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Maria E. C. Schelin
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Research and Development, Skåne University Hospital, Lund, Sweden
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Camartin C, Björkhem-Bergman L. Palliative Sedation—The Last Resort in Case of Difficult Symptom Control: A Narrative Review and Experiences from Palliative Care in Switzerland. Life (Basel) 2022; 12:life12020298. [PMID: 35207585 PMCID: PMC8876692 DOI: 10.3390/life12020298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
Palliative sedation can be considered as “the last resort” in order to treat unbearable, refractory symptoms or suffering in end-of-life patients. The aim is symptom relief and not to induce death as in the case of euthanasia. The treatment might be one of the most challenging therapeutic options in the field of palliative care, involving both ethical and practical issues. Still, studies have shown that it is a safe and valuable treatment and in general does not shorten the life of the patient. Since patients in Switzerland have the legal option of assisted suicide, palliative sedation is an alternative that has become increasingly important. The use of palliative sedation was reported in 17.5% of all patients admitted to palliative care in Switzerland, making the country of those with the highest use of this treatment. The aim of this narrative review is to discuss ethical and practical issues in palliative sedation, with specific focus on experiences from Switzerland. Indications, ethical considerations, drugs of choice and duration are discussed. Decision making should be based on solid guidelines. When used correctly, palliative sedation is an important and useful tool in palliative care in order to provide good symptom relief.
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Affiliation(s)
- Cristian Camartin
- Palliative Care, Kantonsspital Graubünden, Loestrasse 170, CH-7000 Chur, Switzerland
- Correspondence: ; Tel.: +41-81-254-85-23
| | - Linda Björkhem-Bergman
- Division of Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Blickagången 16, SE-141 83 Huddinge, Sweden;
- Palliative Care, Stockholms Sjukhem, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
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Twycross RG, Wong AKY, Vivat B. Comment on Ramos-Rincon et al. Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study. Medicina 2021, 57, 873. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010082. [PMID: 35056390 PMCID: PMC8778193 DOI: 10.3390/medicina58010082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
Abstract
We read with interest the article by Ramos-Rincon and colleagues about patients with COVID-19 dying in acute medical wards in a Spanish University hospital [...].
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Affiliation(s)
| | - Aaron Kee Yee Wong
- Department of Palliative Care, The Royal Melbourne Hospital, 300 Gratton Street, Parkville, VIC 3050, Australia;
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
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Vivat B, Twycross R. CSD Continuous Sedation Until Death; A Response to Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature (Heijltjes et al., 2020). J Pain Symptom Manage 2022; 63:e139-e141. [PMID: 34562594 DOI: 10.1016/j.jpainsymman.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry (B.V.), University College London, London, UK.
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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Heijltjes MT, van Thiel GJMW, Rietjens JAC, van der Heide A, de Graeff A, van Delden JJM. Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature. J Pain Symptom Manage 2020; 60:828-846.e3. [PMID: 32599152 DOI: 10.1016/j.jpainsymman.2020.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/14/2020] [Indexed: 01/10/2023]
Abstract
CONTEXT The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients. OBJECTIVE To gain insight in developments in the use of CSD in various countries and subpopulations. METHODS We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death. RESULTS We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families. CONCLUSIONS The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.
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Affiliation(s)
- Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, The Netherlands and Academic Hospice Demeter, De Bilt, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Chin LTL, Lim YJ, Choo WL. Much Ado About Fried Chicken: Abetting Aspiration or Respecting Autonomy? AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1356-1362. [PMID: 31112667 DOI: 10.1044/2019_ajslp-18-0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose Palliative care is a philosophy of care that encompasses holistic, patient-centric care involving patients and their family members and loved ones. Palliative care patients often have complex needs. A common challenge in managing patients near their end of life is the complexity of navigating clinical decisions and finding achievable and realistic goals of care that are in line with the values and wishes of patients. This often results in differing opinions and conflicts within the multidisciplinary team. Conclusion This article describes a tool derived from the biopsychosocial model and the 4-quadrant ethical model. The authors describe the use of this tool in managing a patient who wishes to have fried chicken despite aspiration risk and how this tool was used to encourage discussions and reduce conflict and distress within the multidisciplinary team.
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Affiliation(s)
- Laurence Tan Lean Chin
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Yishun, Singapore
- Geriatric Education & Research Institute, Singapore, Singapore
| | | | - Wan Ling Choo
- Rehabilitation Department, Khoo Teck Puat Hospital, Yishun, Singapore
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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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Maeda T, Hayakawa T. Effectiveness of Corticosteroid Monotherapy for Dyspnea Relief in Patients with Terminal Cancer. J Pain Palliat Care Pharmacother 2017; 31:148-153. [PMID: 28358257 DOI: 10.1080/15360288.2017.1301618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Dyspnea is a common symptom in patients with cancer, particularly those with late-stage terminal disease. It markedly affects terminal cancer patients, reducing their quality of life. Reduced quality of life also affects survival; therefore, dyspnea is a prognostic factor. However, the role of corticosteroids, which often are used to alleviate dyspnea, has not been sufficiently validated. In this study, we retrospectively investigated whether corticosteroid monotherapy was effective for dyspnea palliation. The effectiveness rate of corticosteroid therapy was 45% in nine male and two female study subjects (mean age: 74.5 years; range: 64-86 years). No significant differences were found between responders and nonresponders in the first-day corticosteroid doses (25.5 ± 10.86 vs. 36.1 ± 16.39 mg, P = .29) or doses administered on 2 days (47.7 ± 25.99 vs. 72.2 ± 32.78 mg, P = .25). The mean ± standard error assessment score changed significantly from 2.7 ± 0.14 at the beginning of corticosteroid administration to 1.5 ± 0.37 at the time of maximum effect (P = .028); however, the decrease to 2.1 ± 0.25 at the final administration was not significant (P = .068). This indicates that corticosteroid therapy relieved dyspnea and could provide an early-stage treatment option.
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A systematic literature review on the ethics of palliative sedation: an update (2016). Curr Opin Support Palliat Care 2016; 10:201-7. [DOI: 10.1097/spc.0000000000000224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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