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Kwon S, Kim M, Choi S. Ethical dilemmas and care actions in nurses providing palliative sedation. Nurs Ethics 2022; 29:1220-1230. [PMID: 35728273 DOI: 10.1177/09697330221105639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recently, palliative care is increasingly important, with an emphasis on the process of dying with dignity. However, nurses who care for such patients experience the associated ethical dilemmas. OBJECTIVE To explore the meaning of nurses' experiences in dealing with ethical dilemmas in relation to palliative sedation. RESEARCH DESIGN A qualitative research design was employed with a thematic analysis approach. PARTICIPANTS AND RESEARCH CONTEXT Using purposive sampling, 15 nurses, working at palliative care units for at least 1 year, were recruited as participants. Data were collected using unstructured in-depth interviews, and data collection and analysis was performed simultaneously. ETHICAL CONSIDERATIONS Ethical approval was obtained from the authors' institutional review board. All participants provided informed consent. For the face-to-face interview, the South Korean standard COVID-19 quarantine guidelines, such as mandatory masking and social distancing, were followed. RESULTS Dilemmas raised by patients, were related to concerns about appropriate drug dose; dilemmas raised by nurses, were related to passive care, sense of guilt for failure to predict death, and colleague's disrespectful attitudes toward patients; dilemmas from patients' families were related to demands for palliative sedation and reversal of those demands. Care actions to deal with ethical dilemmas comprised evidence-based care, person-centered thinking, reflecting on the death situation, compassion, providing explanation and help to family members. CONCLUSION Nurses' ethical dilemmas were pre-dominantly influenced by themselves, rather than by the patients or their families, especially if they felt they could not do their best for patients. The core concept of care actions to deal with the ethical dilemmas, was person-centered care and compassion. Then, how patients and their family members perceive person-centered care and compassion, should be further explored to improve palliative sedation.
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Affiliation(s)
- Sinyoung Kwon
- Department of Nursing, 250458Gangdong University, Eumseong-gun, Chungcheongbuk-do, Korea
| | | | - Sujin Choi
- 35031Woosuk University, Wanju, Jeollabuk-do, Korea
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Basilicata P, Giugliano P, Vacchiano G, Simonelli A, Guadagni R, Silvestre A, Pieri M. Forensic Toxicological and Medico-Legal Evaluation in a Case of Incongruous Drug Administration in Terminal Cancer Patients. TOXICS 2021; 9:toxics9120356. [PMID: 34941790 PMCID: PMC8704381 DOI: 10.3390/toxics9120356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/03/2021] [Accepted: 12/15/2021] [Indexed: 11/28/2022]
Abstract
Background: In most cases, palliative care is prescribed to adults diagnosed with cancer. The definition of the most suitable therapy for an effective sedation in terminal cancer patients still represents one of the most challenging goals in medical practice. Due to their poor health, the correct dosing of drugs used for deep palliative sedation in terminal cancer patients, often already on polypharmacological therapy, can be extremely complicated, also considering possible drug-to-drug interactions that could lead to an increased risk of overdose and/or incongruous administration with fatal outcomes. The case of a terminal cancer patient is presented, focusing on the “adequacy” of administered therapy. Materials and Methods: A young male, affected by Ewing sarcoma, attending a palliative care at his own home, died soon after midazolam administration. Toxicological and histological analyses were performed on body fluids and organ fragments. Results and Discussion: Morphological reliefs evidenced a neoplastic mass, composed of lobulated tissue with a lardy, pinkish-gray consistency, extending from the pleural surface to the lung parenchyma, also present at the sacrum region (S1–S5), at the anterior mediastinum level, occupying the entire left pleural cavity, and infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. The brain presented edema and congestion. Toxicological analyses evidenced blood midazolam concentrations in the range of 0.931–1.690 µg/mL, while morphine was between 0.266 and 0.909 µg/mL. Death was attributed to cardiorespiratory depression because of a synergic action between morphine and midazolam. The pharmacological interaction between midazolam and morphine is discussed considering the clinical situation of the patient. The opportunity to proceed with midazolam administration is discussed starting from guidelines recommendation. Finally, professional liability outlines are highlighted.
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Affiliation(s)
- Pascale Basilicata
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Pasquale Giugliano
- Legal Medicine Section, AORN “Sant’Anna e San Sebastiano” Caserta, 81100 Caserta, Italy;
| | - Giuseppe Vacchiano
- Department of Law, Economics and Mathematical Methods, University of Sannio, 82100 Benevento, Italy;
| | - Angela Simonelli
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Rossella Guadagni
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Angela Silvestre
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
| | - Maria Pieri
- Legal Medicine Section, Department of Advanced Biomedical Science, University of Naples “Federico II”, 80131 Naples, Italy; (P.B.); (A.S.); (R.G.); (A.S.)
- Correspondence: ; Tel.: +39-0817463474; Fax: +39-0817464726
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Arantzamendi M, Belar A, Payne S, Rijpstra M, Preston N, Menten J, Van der Elst M, Radbruch L, Hasselaar J, Centeno C. Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review. J Pain Symptom Manage 2021; 61:831-844.e10. [PMID: 32961218 DOI: 10.1016/j.jpainsymman.2020.09.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022]
Abstract
CONTEXT Near the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed. OBJECTIVES To explore clinical aspects of palliative sedation in recent prospective studies. METHODS Systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019), combining sedation, palliative care, and prospective. Article quality was assessed. RESULTS Ten prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%-83%), pain (25%-65%), and dyspnea (16%-59%). In some articles, psychological and existential distress were mentioned (16%-59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication-propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort. CONCLUSION Assessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.
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Affiliation(s)
- Maria Arantzamendi
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain
| | - Alazne Belar
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain.
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Johan Menten
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Van der Elst
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitaetsklinikum Bonn, Bonn, Germany
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Carlos Centeno
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain; Clínica Universidad de Navarra, Departamento Medicina Paliativa, Pamplona, Spain
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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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Díez-Manglano J, Isasi de Isasmendi Pérez S, García Fenoll R, Sánchez LÁ, Formiga F, Giner Galvañ V, Dueñas C, Roca B, Estrada Díaz C, Casariego Vales E. Palliative Sedation in Patients Hospitalized in Internal Medicine Departments. J Pain Symptom Manage 2020; 59:302-309. [PMID: 31655190 DOI: 10.1016/j.jpainsymman.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Palliative sedation is used to relieve end-of-life refractory symptoms. OBJECTIVE The objective of this study was to describe the use of palliative sedation in patients who die in internal medicine departments. METHODS An observational, cross-sectional, retrospective, and multicenter clinical audit study was conducted in 145 hospitals in Spain and Argentina. Each hospital included the first 10 patients who died in the internal medicine department, starting on December 1, 2015. RESULTS We included 1447 patients, and palliative sedation was administered to 701 patients (48.4%). Having a terminal illness (odds ratio [OR] 2.469, 95% CI 1.971-3.093, P < 0.001) and the length of hospital stay (OR 1.011, 95% CI 1.002-1.021, P = 0.017) were independently associated with the use of palliative sedation. Consent was granted by the families of 582 (83%) patients. The most common refractory symptom was dyspnea, and the most commonly used drugs for sedation were midazolam (77%) and morphine (89.7%). An induction dose was administered in 25.7% of the patients. Rescue doses were scheduled for 70% of the patients, and hydration was maintained in 49.5%. Pain was more common in patients with cancer, whereas dyspnea was more common in those without cancer. Rescue doses were used more often for the patients with cancer (77.8% vs. 67.7%, P = 0.015). Monitoring the palliative sedation with a scale was more frequent in the patients with cancer (23.7% vs. 14.3%, P = 0.008). CONCLUSIONS Palliative sedation is used more often for terminal patients. There are differences in the administration of palliative sedation between patients with and without cancer.
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Affiliation(s)
| | | | | | - Luis Ángel Sánchez
- Internal Medicine Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Françesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Spain
| | | | - Carlos Dueñas
- Internal Medicine Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Bernardino Roca
- Internal Medicine Department, Hospital General Universitario, Castellón, Spain
| | - Cristina Estrada Díaz
- Internal Medicine Department, Hospital Universitario Mutua de Tarrassa, Tarrassa, Spain
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Prommer E. Midazolam: an essential palliative care drug. Palliat Care Soc Pract 2020; 14:2632352419895527. [PMID: 32215374 PMCID: PMC7065504 DOI: 10.1177/2632352419895527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022] Open
Abstract
Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid. Gamma-aminobutyric acid action promotes sedative, anxiolytic, and anticonvulsant properties. Midazolam has a faster onset and shorter duration of action than other benzodiazepines such as diazepam and lorazepam lending itself to greater flexibility in dosing than other benzodiazepines. The kidneys excrete midazolam and its active metabolite. Metabolism occurs in the liver by the P450 system. This article examines the pharmacology, pharmacodynamics, and clinical uses of midazolam in palliative care.
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Affiliation(s)
- Eric Prommer
- UCLA/VA Hospice and Palliative Medicine Program, UCLA School of Medicine, 11301 Wilshire Blvd., Bldg. 500, Room 2064A, Los Angeles, CA 90073, USA
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Setla J, Pasniciuc SV. Home Palliative Sedation Using Phenobarbital Suppositories: Time to Death, Patient Characteristics, and Administration Protocol. Am J Hosp Palliat Care 2019; 36:871-876. [PMID: 30947512 DOI: 10.1177/1049909119839695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Most people in the United States and other countries cite their preferred location of death as their homes. However, intractable symptoms sometimes require hospitalization, especially if significant sedation becomes necessary. For over a decade, Hospice of Central New York has been using compounded phenobarbital suppositories with individuals in whom adequate sedation has not been achieved using sufficient doses of antipsychotics or benzodiazepines but prefer to remain in their homes. OBJECTIVES (1) Describe the use of phenobarbital suppositories in homes for the purpose of sedation. (2) Understand patient characteristics of potential users and those in whom suppositories were actually used. (3) Measure time to death after initiating the phenobarbital suppositories. SETTING Medicare-certified not-for-profit hospice organization in New York State. METHOD Retrospective case series. RESULTS Of 1675 patients enrolled in hospice over an 18-month period, phenobarbital suppositories were placed in the homes of 90 patients for potential use. Suppositories were initiated in 31 of the 90 patients. Agitated delirium was the major symptom for which suppositories were placed and initiated. Both groups had a greater prevalence of cancer diagnoses than the target population. The mean time to death after initiation of phenobarbital suppositories was 38.8 hours. None of the users were hospitalized. CONCLUSION The use of compounded phenobarbital suppositories for the purpose of palliative sedation is an alternative for patients and families who desire to remain home despite refractory symptoms.
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Affiliation(s)
- Judith Setla
- 1 Hospice of Central New York, Liverpool, NY, USA.,2 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Silviu Valeriu Pasniciuc
- 1 Hospice of Central New York, Liverpool, NY, USA.,2 State University of New York Upstate Medical University, Syracuse, NY, USA
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Delgado-Ortega L, González-Domínguez A, Borrás JM, Oliva-Moreno J, González-Haba E, Menjón S, Pérez P, Vicente D, Cordero L, Jiménez M, Simón S, Hidalgo-Vega Á, Moya-Alarcón C. The economic burden of disease of epithelial ovarian cancer in Spain: the OvarCost study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:135-147. [PMID: 29922900 PMCID: PMC6394604 DOI: 10.1007/s10198-018-0986-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/06/2018] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the economic burden of epithelial ovarian cancer (EOC) in incident patients and the burden by disease stage in Spain. METHODS We developed a Markov model from a social perspective simulating the natural history of EOC and its four stages, with a 10-year time horizon, 3-week cycles, 3% discount rate, and 2016 euros. Healthcare resource utilization and costs were estimated by disease stage. Direct healthcare costs (DHC) included early screening, genetic counselling, medical visits, diagnostic tests, surgery, chemotherapy, hospitalizations, emergency services, and palliative care. Direct non-healthcare costs (DNHC) included formal and informal care. Indirect costs (IC) included labour productivity losses due to temporary and permanent leaves, and premature death. Epidemiology data and resource use were taken from the literature and validated for Spain by the OvarCost group using a Delphi method. RESULTS The total burden of EOC over 10 years was 3102 mill euros: 15.1% in stage I, 3.9% in stage II, 41.0% in stage III, and 40.2% in stage IV. Annual average cost/patient was €24,111 and it was €8,641; €14,184; €33,858, and €42,547 in stages I-IV, respectively. Of total costs, 71.2% were due to DHC, 24.7% to DNHC, and 4.1% to IC. CONCLUSIONS EOC imposes a significant economic burden on the national healthcare system and society in Spain. Investment in better early diagnosis techniques might increase survival and patients' quality of life. This would likely reduce costs derived from late stages, consequently leading to a substantial reduction of the economic burden associated with EOC.
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Affiliation(s)
- Laura Delgado-Ortega
- AstraZeneca Farmacéutica Spain, Serrano Galvache, 56, Building Álamo, Madrid Spain
| | | | - Josep María Borrás
- Clinical Sciences Department, University of Barcelona, L’Hospital de Llobregat, Barcelona Spain
| | | | | | - Salomón Menjón
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Pedro Pérez
- Hospital Clínico Universitario, Madrid, Spain
| | - David Vicente
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Luis Cordero
- AstraZeneca Farmacéutica Spain, Serrano Galvache, 56, Building Álamo, Madrid Spain
| | | | - Susana Simón
- AstraZeneca Farmacéutica Spain, Serrano Galvache, 56, Building Álamo, Madrid Spain
| | | | - Carlota Moya-Alarcón
- AstraZeneca Farmacéutica Spain, Serrano Galvache, 56, Building Álamo, Madrid Spain
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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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Cost–utility analysis of germline BRCA1/2 testing in women with high-grade epithelial ovarian cancer in Spain. Clin Transl Oncol 2019; 21:1076-1084. [DOI: 10.1007/s12094-018-02026-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
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