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Guité-Verret A, Boivin J, Hanna AMR, Downar J, Bush SH, Marcoux I, Guay D, Tapp D, Lapenskie J, Gagnon B. Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences. BMC Palliat Care 2024; 23:104. [PMID: 38637812 PMCID: PMC11027280 DOI: 10.1186/s12904-024-01426-2] [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: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.
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Affiliation(s)
- Alexandra Guité-Verret
- Department of Psychology, Université du Québec à Montréal, Montréal, Canada
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
| | - Jessica Boivin
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
| | | | - James Downar
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Isabelle Marcoux
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Diane Guay
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Diane Tapp
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bruno Gagnon
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada.
- CHU Québec-Université Laval Research Centre, Québec, Canada.
- Bruyère Research Institute, Ottawa, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, Canada.
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Surges SM, Brunsch H, Jaspers B, Apostolidis K, Cardone A, Centeno C, Cherny N, Csikós À, Fainsinger R, Garralda E, Ling J, Menten J, Mercadante S, Mosoiu D, Payne S, Preston N, Van den Block L, Hasselaar J, Radbruch L. Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study. Palliat Med 2024; 38:213-228. [PMID: 38297460 PMCID: PMC10865771 DOI: 10.1177/02692163231220225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING European. PARTICIPANTS International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.
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Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | | | - Antonella Cardone
- Cancer Patients Europe, Brussels, Belgium
- Pancreatic Cancer Europe, Brussels, Belgium
| | - Carlos Centeno
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Nathan Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Àgnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | | | - Eduardo Garralda
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Johan Menten
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative/Supportive Care, La Maddalena Cancer Centre, Palermo, Italy
| | - Daniela Mosoiu
- Medical Faculty, Transilvania University, Brasov, Romania
- Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jeroen Hasselaar
- Department of Primary Care, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
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Rodrigues P, Ostyn J, Mroz S, Ronse A, Menten J, Gastmans C. Palliative care physicians' decision-making about palliative sedation for existential suffering: A Belgian nationwide qualitative study. Palliat Support Care 2024; 22:119-127. [PMID: 36503696 DOI: 10.1017/s1478951522001559] [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: 12/14/2022]
Abstract
OBJECTIVES This study aims to provide an in-depth understanding of the content and process of decision-making about palliative sedation for existential suffering (PS-ES) as perceived by Belgian palliative care physicians. METHODS This Belgian nationwide qualitative study follows a grounded theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 19 Belgian hospital-based palliative care units and 4 stand-alone hospices. We analyzed the data using the Qualitative Analysis Guide of Leuven, and we followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ). RESULTS Analysis of the data identified several criteria that physicians apply in their decision-making about PS-ES, namely, the importance of the patient's demand, PS-ES as a last resort option after all alternatives have been applied, the condition of unbearable suffering combined with other kinds of suffering, and the condition of being in a terminal stage. Regarding the process of decision-making itself, physicians refer to the need for multidisciplinary perspectives supported by an interpretative dialogue with the patient and all other stakeholders. The decision-making process involves a specific temporality and physicians' inner conviction about the need of PS-ES. SIGNIFICANCE OF RESULTS Belgian palliative care physicians are not sure about the criteria regarding decision-making in PS-ES. To deal with complex existential suffering in end-of-life situations, they stress the importance of participation by all stakeholders (patient, relatives, palliative care team, other physicians, nurses, social workers, physiotherapists, occupational therapists, chaplains, etc.) in the decision-making process to prevent inadequate decisions being made.
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Affiliation(s)
| | - Jozefien Ostyn
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Sarah Mroz
- End-of-Life Care Research Group, Free University of Brussels (VUB), Brussels, Belgium
| | - Axelle Ronse
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Johan Menten
- Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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Van der Elst M, Payne S, Arantzamendi M, Preston N, Hasselaar J, Centeno C, Belar A, Jaspers B, Brunsch H, Surges S, Adile C, Menten J. An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study. BMC Palliat Care 2022; 21:227. [PMID: 36550539 PMCID: PMC9783747 DOI: 10.1186/s12904-022-01117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. METHODS This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. DISCUSSION The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.
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Affiliation(s)
- M. Van der Elst
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - S. Payne
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - M. Arantzamendi
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - N. Preston
- grid.9835.70000 0000 8190 6402International Observatory On End of Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, LA1 4AT UK
| | - J. Hasselaar
- grid.5590.90000000122931605Department of Anesthesiology, Pain and Palliative Medicine, Radboud University and Radboudumc, Geert Grote Plein 10, HB6500 Nijmegen, Netherlands
| | - C. Centeno
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain ,grid.411730.00000 0001 2191 685XClínica Universidad de Navarra, Palliative Medicine Department, Pamplona, Spain
| | - A. Belar
- grid.5924.a0000000419370271Institute for Culture and Society-ATLANTES, Universidad de Navarra, Calle Universidad 6, Navarra 31009 Pamplona, Spain ,grid.508840.10000 0004 7662 6114IdISNA- Instituto de Investigación Sanitaria de Navarra. Palliative Medicine, Pamplona, Spain
| | - B. Jaspers
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - H. Brunsch
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - S. Surges
- grid.15090.3d0000 0000 8786 803XDepartment of Palliative Medicine, Universitätsklinikum Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - C. Adile
- grid.10776.370000 0004 1762 5517La Maddalena Cancer Center, Via San Lorenzo 312, 90146 Palermo, Italy
| | - J. Menten
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Radiotherapy, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
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Morita T, Kawahara T, Stone P, Sykes N, Miccinesi G, Klein C, Stiel S, Hui D, Deliens L, Heijltjes MT, Mori M, Heckel M, Robijn L, Krishna L, Rietjens J. Intercountry and intracountry variations in opinions of palliative care specialist physicians in Germany, Italy, Japan and UK about continuous use of sedatives: an international cross-sectional survey. BMJ Open 2022; 12:e060489. [PMID: 35459681 PMCID: PMC9036469 DOI: 10.1136/bmjopen-2021-060489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To explore intercountry and intracountry differences in physician opinions about continuous use of sedatives (CUS), and factors associated with their approval of CUS. SETTINGS Secondary analysis of a questionnaire study. PARTICIPANTS Palliative care physicians in Germany (N=273), Italy (N=198), Japan (N=334) and the UK (N=111). PRIMARY AND SECONDARY OUTCOME MEASURES Physician approval for CUS in four situations, intention and treatment goal, how to use sedatives and beliefs about CUS. RESULTS There were no significant intercountry or intracountry differences in the degree of agreement with statements that (1) CUS is not necessary as suffering can always be relieved with other measures (mostly disagree); (2) intention of CUS is to alleviate suffering and (3) shortening the dying process is not intended. However, there were significant intercountry differences in agreement with statements that (1) CUS is acceptable for patients with longer survival or psychoexistential suffering; (2) decrease in consciousness is intended and (3) choice of neuroleptics or opioids. Acceptability of CUS for patients with longer survival or psychoexistential suffering and whether decrease in consciousness is intended also showed wide intracountry differences. Also, the proportion of physicians who agreed versus disagreed with the statement that CUS may not alleviate suffering adequately even in unresponsive patients, was approximately equal. Regression analyses revealed that both physician-related and country-related factors were independently associated with physicians' approval of CUS. CONCLUSION Variations in use of sedatives is due to both physician- and country-related factors, but palliative care physicians consistently agree on the value of sedatives to aid symptom control. Future research should focus on (1) whether sedatives should be used in patients with longer survival or with primarily psychoexistential suffering, (2) understanding physicians' intentions and treatment goals, (3) efficacy of different drugs and (4) understanding the actual experiences of patients receiving CUS.
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Affiliation(s)
- Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Hamamatsu, Shizuoka, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Guido Miccinesi
- Department of Oncological Network, Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nürnberg, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, University of Texas, Austin, Texas, USA
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Madelon T Heijltjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Masanori Mori
- Palliative and Supportive care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Lenzo Robijn
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lalit Krishna
- The Division of Supportive and Palliative Care, National Cancer Center Singapore, National Cancer Center Singapore, Singapore
| | - Judith Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.,Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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8
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Tomczyk M, Schumacher BN. Nurses' experience with palliative sedation procedures in line with the 2005 Swiss guidelines: an exploratory study. Can Oncol Nurs J 2020; 30:261-268. [PMID: 33165398 DOI: 10.5737/23688076304261268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Many international studies have shown that the process of palliative sedation in an end-of-life context can be an adverse, even emotionally distressing experience for nurses. However, to the best of our knowledge, the experience of nurses working in palliative care in Switzerland has never been explored. The purpose of our study was, therefore, to understand and describe nurses' experience with the process of palliative sedation in line with the Swiss guidelines developed in 2005. We opted for an exploratory qualitative monocentric study using comprehensive individual interviews to achieve this objective. A total of 10 nurses were approached, and nine agreed to take part. After the interviews were transcribed, eight were ultimately included in the analysis. This analysis shows that nurses' attitudes toward the process of palliative sedation tended to be hesitant, resistant, or confident and that this was linked to the length of time they had worked in palliative care. These findings suggest that the 2005 Swiss guidelines do not protect nurses against the uncertainty related to process of palliative sedation. A national comprehensive multicentric study therefore needs to be developed to consolidate these results.
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Affiliation(s)
- Martyna Tomczyk
- Medical Ethics Researcher, PhD, Postdoctoral Fellow, Institute of Humanities in Medicine, Lausanne University Hospital (CHUV), Avenue de Provence 82, CH-1007 Lausanne, Switzerland, , +33 (0)6 95 11 86 45
| | - Bernard N Schumacher
- Philosopher, Professor, PhD-HDR, Coordinator, Interdisciplinary Institute of Ethics and Human Rights, University of Fribourg, Switzerland. Avenue de Beauregard 13, CH-1700 Fribourg, Switzerland,
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Rodrigues P, Menten J, Gastmans C. Physicians' perceptions of palliative sedation for existential suffering: a systematic review. BMJ Support Palliat Care 2019; 10:136-144. [PMID: 31481477 DOI: 10.1136/bmjspcare-2019-001865] [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] [Received: 04/17/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Palliative sedation for existential suffering (PS-ES) is a controversial clinical intervention. Empirical studies about physicians' perceptions do not converge in a clear position and current clinical practice guidelines do not agree either regarding this kind of intervention. AIM To gain deeper insight into physicians' perceptions of PS-ES, the factors influencing it, the conditions for implementing it and the alternatives to it. DESIGN Systematic review of qualitative, quantitative and mixed-methods studies following the Peer Review Electronic Search Strategies and Preferred Reporting Items for Systematic Reviews and Meta-analyses protocols; quality appraisal and thematic synthesis methodology. DATA SOURCES Seven electronic databases (PubMed, CINAHL, Embase, Scopus, Web of Science, PsycINFO, PsycARTICLES) were exhaustively searched from inception through March 2019. Two reviewers screened paper titles, abstracts and full texts. We included only peer-reviewed journal articles published in English, French, German, Dutch, Spanish, Italian or Portuguese that focused on physicians' perceptions of PS-ES. RESULTS The search yielded 17 publications published between 2002 and 2017. Physicians do not hold clear views or agree if and when PS-ES is appropriate. Case-related and individual-related factors that influenced physicians' perceptions were identified. There is still no consensus regarding criteria to distinguish between necessary and sufficient conditions for invoking PS-ES. Some alternatives to PS-ES were identified. CONCLUSIONS To date, there is still no consensus on physicians' perceptions of PS-ES. Further research is necessary to understand factors that influence physicians' perceptions and philosophical-ethical presuppositions underlying this perceptions.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS 7446 - Centre d'éthique médicale, Université Catholique de Lille, Lille, France
| | - Johan Menten
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Chris Gastmans
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Falconer J, Couture F, Demir KK, Lang M, Shefman Z, Woo M. Perceptions and intentions toward medical assistance in dying among Canadian medical students. BMC Med Ethics 2019; 20:22. [PMID: 30940195 PMCID: PMC6444527 DOI: 10.1186/s12910-019-0356-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 03/11/2019] [Indexed: 11/16/2022] Open
Abstract
Background Medical assistance in dying (MAID) was legalized in Canada in 2016. As of July 2017, approximately 2149 patients have accessed MAID. There remains no national-level data on the perspectives of future physicians about MAID or its changing legal status. We provide evidence from a national survey of Canadian medical students about their opinions, intentions, and concerns about MAID. Methods From October 2016 to July 2017, we distributed an anonymous online survey to all students at 15 of Canada’s 17 medical schools. The survey collected data on respondent socio-demographic characteristics, features of their medical education, intentions for medical practice, and perspectives on MAID. We analyzed responses using univariate descriptive and stepwise multivariate logistic regression. Results In 1210 completed surveys, 71% of respondents reported being willing to provide MAID under a legal framework that permits it. Non-religious respondents reported greater willingness to participate in MAID than respondents of any religious affiliation (p < 0.001). Frequency of religious attendance was inversely associated with willingness to provide MAID (p < 0.001). Medical students born in Québec were more willing to provide MAID than respondents from other provinces (OR 2.21; p < 0.001). Age, sex, socioeconomic status, year of medical study, previous academic major, and rural/urban city of birth were not associated with willingness to provide MAID. Conclusion As the current class of medical students becomes the first cohort of new physicians to enter Canada’s changing medical and legal landscape around MAID, our findings inform the public debate by examining attributes associated with support or opposition to the practice. Electronic supplementary material The online version of this article (10.1186/s12910-019-0356-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Félix Couture
- Department of Surgery, Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Koray K Demir
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Michael Lang
- Department of Human Genetics, McGill University, Montreal, Québec, Canada
| | | | - Mark Woo
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Pérez de Llano LA. Cuidados paliativos para pacientes con insuficiencia respiratoria crónica. GACETA SANITARIA 2018; 32:383-385. [DOI: 10.1016/j.gaceta.2018.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 12/01/2022]
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Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F. Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry 2016; 16:260. [PMID: 27450328 PMCID: PMC4957930 DOI: 10.1186/s12888-016-0970-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/14/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND As a significant proportion of patients receiving palliative care suffer from states of anxiety, depression, delirium, or other mental symptoms, psychiatry and palliative care already collaborate closely in the palliative care of medical conditions. Despite this well-established involvement of psychiatrists in palliative care, psychiatry does not currently explicitly provide palliative care for patients with mental illness outside the context of terminal medical illness. DISCUSSION Based on the WHO definition of palliative care, a, a working definition of palliative psychiatry is proposed. Palliative psychiatry focuses on mental health rather than medical/physical issues. We propose that the beneficiaries of palliative psychiatry are patients with severe persistent mental illness, who are at risk of therapeutic neglect and/or overly aggressive care within current paradigms. These include long-term residential care patients with severe chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa. An explicitly palliative approach within psychiatry has the potential to improve quality of care, person-centredness, outcomes, and autonomy for patients with severe persistent mental illness. CONCLUSIONS The first step towards a palliative psychiatry is to acknowledge those palliative approaches that already exist implicitly in psychiatry. Basic skills for a palliative psychiatry include communication of diagnosis and prognosis, symptom assessment and management, support for advance (mental health) care planning, assessment of caregiver needs, and referral to specialized services. Some of these may already be considered core skills of psychiatrists, but for a truly palliative approach they should be exercised guided by an awareness of the limited functional prognosis and lifespan of patients with severe persistent mental illness.
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Affiliation(s)
- Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland. .,Department of Psychiatry, Cedars-Sinai Health System, Los Angeles, CA, USA.
| | - Scott A. Irwin
- Supportive Care Services, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Health System, Los Angeles, CA USA ,Department of Psychiatry, Cedars-Sinai Health System, Los Angeles, CA USA
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006 Zurich, Switzerland
| | - Paul Hoff
- Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Florian Riese
- Psychiatric University Hospital Zurich, Zurich, Switzerland ,URPP “Dynamics of Healthy Aging”, University of Zurich, Zurich, Switzerland
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Anneser J, Jox RJ, Thurn T, Borasio GD. Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students. GMS JOURNAL FOR MEDICAL EDUCATION 2016; 33:Doc11. [PMID: 26958648 PMCID: PMC4766939 DOI: 10.3205/zma001010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES In November 2015, the German Federal Parliament voted on a new legal regulation regarding assisted suicide. It was decided to amend the German Criminal Code so that any "regular, repetitive offer" (even on a non-profit basis) of assistance in suicide would now be considered a punishable offense. On July 2, 2015, a date which happened to be accompanied by great media interest in that it was the day that the first draft of said law was presented to Parliament, we surveyed 4th year medical students at the Technical University Munich on "physician-assisted suicide," "euthanasia" and "palliative sedation," based on a fictitious case vignette study. METHOD The vignette study described two versions of a case in which a patient suffered from a nasopharyngeal carcinoma (physical suffering subjectively perceived as being unbearable vs. emotional suffering). The students were asked about the current legal norms for each respective course of action as well as their attitudes towards the ethical acceptability of these measures. RESULTS Out of 301 students in total, 241 (80%) participated in the survey; 109 answered the version 1 questionnaire (physical suffering) and 132 answered the version 2 questionnaire (emotional suffering). The majority of students were able to assess the currently prevailing legal norms on palliative sedation (legal) and euthanasia (illegal) correctly (81.2% and 93.7%, respectively), while only a few students knew that physician-assisted suicide, at that point in time, did not constitute a criminal offense. In the case study that was presented, 83.3% of the participants considered palliative sedation and the simultaneous withholding of artificial nutrition and hydration as ethically acceptable, 51.2% considered physician-assisted suicide ethically legitimate, and 19.2% considered euthanasia ethically permissible. When comparing the results of versions 1 and 2, a significant difference could only be seen in the assessment of the legality of palliative sedation: it was considered legal more frequently in the physical suffering version (88.1% vs. 75.8%). CONCLUSION The majority of the students surveyed wrongly assumed that physician-assisted suicide is a punishable offense in Germany. However, a narrow majority considered physician-assisted suicide ethically acceptable in the case study presented. Compared to euthanasia, more than twice as many participants considered physician-assisted suicide acceptable. There was no significant difference between personal attitudes towards palliative sedation, physician-assisted suicide or euthanasia in light of physical or emotional suffering. Educational programs in this field should be expanded both qualitatively and quantitatively, especially considering the relevance of the subject matter, the deficits within the knowledge of legal norms and the now even higher complexity of the legal situation due to the new law from December 2015.
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Affiliation(s)
- Johanna Anneser
- TU München, Klinikum rechts der Isar, Klinik für Psychosomatische Medizin und Psychotherapie, Palliativmedizinischer Dienst, München, Deutschland
| | - Ralf J. Jox
- LMU München, Institut für Ethik, Geschichte und Theorie der Medizin, München, Deutschland
| | - Tamara Thurn
- TU München, Klinikum rechts der Isar, Klinik für Psychosomatische Medizin und Psychotherapie, Palliativmedizinischer Dienst, München, Deutschland
| | - Gian Domenico Borasio
- Universität Lausanne, Centre Hospitalier Universitaire Vaudois (CHUV), Service de Soins Palliatifs, Lausanne, Schweiz
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