Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer

How should respiratory depression and loss of airway patency be handled during initiation of palliative sedation?

BACKGROUND

Loss of airway patency has been reported during initiation of palliative sedation. In present guidelines the loss of airway patency during initiation of palliative sedation is not addressed. Airway patency can be restored by jaw thrust/chin lift or placing the patient in the recovery position.

AIM

A structured ethical analysis of how respiratory depression and loss of airway patency during initiation of palliative sedation should be handled. The essence of the dilemma is whether it is appropriate to apply simple non-invasive methods to restore airway patency in order to avoid the patient's immediate death.

DESIGN

A structured analysis based on the four principles of healthcare ethics and stakeholders' interests.

RESULTS

Beneficence and autonomy support a decision not to regain airway patency whereas non-maleficence lends weight to a decision to restore airway patency. Whether the proportionality criterion of the principle of double effect is met depends on the features of the individual case. The ethical problem appears to be a genuine dilemma where important values and arguments point to different conclusions.

CONCLUSION

Whether to restore airway patency when the airway is obstructed during initiation of palliative sedation will ultimately be based on clinical judgment taking into account both any known patient preferences and relevant clinical information. There are strong arguments favoring both options in this clinical and ethical dilemma. The fact that a clear and universal recommendation cannot be made does not imply indifference regarding what is the clinically and ethically best option for each individual patient.

Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences

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.

'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium

BACKGROUND

Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting.

AIM(S)

To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care.

DESIGN

Qualitative interview study using behaviour change theory from a critical realist stance.

SETTING/PARTICIPANTS

Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices.

RESULTS

We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this.

CONCLUSIONS

Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

The practices of nurses about palliative sedation on palliative care wards: A qualitative study

AIM

To describe the practices of nurses concerning palliative sedation in palliative care wards in hospitals.

DESIGN

Qualitative descriptive design.

METHODS

A total of 27 nurses were interviewed in six focus groups and one pair interview; the nurses worked on four palliative care wards in three Finnish hospitals and the interviews took place between May and November 2019. The data were analysed using inductive content analysis. The COREQ checklist was used as a guide for reporting this study.

FINDINGS

Three main categories describing nurses' practices concerning palliative sedation were identified: participation in palliative sedation decision-making, sedation implementation and monitoring and information sharing and compassionate care for the patient and relatives.

CONCLUSIONS

Nurses play a key role throughout palliative sedation on palliative care wards in hospitals. To develop the quality of care, it is recommended to specify the role of nurses in palliative sedation, increase cooperation between nurses and physicians, and enhance palliative sedation education for nurses.

Ethical dilemmas and care actions in nurses providing palliative sedation

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.

Challenges and Strategies Regarding Sedation at the End of Life in Hospitals and Nursing Homes

CONTEXT

Sedation is an accepted, but controversially discussed and challenging measure to treat suffering at the end of life. Although most people die in hospitals or nursing homes, little is known how professionals in these settings deal with sedatives and sedation at the end of life.

OBJECTIVES

To explore 1) challenges regarding use of sedatives and sedation at the end of life in hospitals and nursing homes, and 2) strategies, and supportive measures to meet these challenges, as perceived by nurses and physicians.

METHODS

Multicenter qualitative interview study. Forty-nine participants: 12 general practitioners and 12 nurses from five nursing homes, 12 physicians, and 13 nurses from five hospital departments (hematology/oncology (n = 2), neurology, geriatrics, gynecology). Semi-structured qualitative interviews. Data analysis guided by framework approach.

RESULTS

Perceived challenges relate to three levels of the care situation: individual, interaction with others, and work environment. The main challenge was defining the adequate timing and/or dose. Other challenges, e.g., disagreements regarding indication or legal uncertainties, were highly interrelated, and strongly associated with this major challenge. Reported strategies and supportive measures to address challenges also corresponded to the three interrelated levels. Major named strategies were education and training, joint decision-making within the team and regular discussion with the patient and family. On the level work environment, no implemented strategies, but wishes for change were identified.

CONCLUSION

To meet the identified challenges in a sustainable way and enable continuous improvement of quality of care, best practice recommendations, and other supportive measures have to address all identified levels of challenges.

The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis

BACKGROUND

Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting.

AIM

To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts.

DESIGN

Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417).

DATA SOURCES

The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers.

RESULTS

A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care.

CONCLUSIONS

Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.

Perception, Beliefs, and Attitudes Regarding Sedation Practices among Palliative Care Nurses and Physicians: A Qualitative Study

Background: Palliative care teams face complex medical situations on a daily basis. These situations require joint reflection and decision making to propose appropriate patient care. Sometimes, sedation is one of the options to be considered. In addition to medical and technical criteria justifying the use of sedation, multiple psychosocial criteria impact the decision making of palliative care teams and guide, give sense to, and legitimize professional practices.

Objective: The main goal of this study was to explore perceptions, experiences, and beliefs of palliative care teams about sedation practices in a legislative context (Claeys–Leonetti law, 2016; France), which authorizes continuous deep sedation (CDS) until death.

Methods: This is a qualitative study using 28 semistructured interviews with physicians and nurses working in a palliative care team in France (PACA region). All verbal productions produced during interviews were fully transcribed and the contents analyzed.

Findings: Content analysis revealed four themes: (1) sedation as a “good death,” (2) emotional experiences of sedations, (3) the practice of CDS, and (4) the ambiguous relationship with the Claeys–Leonetti law.

Conclusions: This qualitative study provides evidence of a form of “naturalization” of the practice of sedation. However, the Claeys–Leonetti law exacerbates differences of opinion between palliative caregivers on sedation and questions the interest of this law for society and palliative care practices.

clinicalTrials.gov identifier: NCT04016038.

The practices and attitudes of nurses regarding palliative sedation: A scoping review

BACKGROUND

Palliative sedation is used as a last-resort option to treat refractory symptoms of dying patients. Nurses are important participants in the process of sedation. However, little is known about palliative sedation from a nursing perspective.

OBJECTIVES

To analyze the practices and attitudes of nurses concerning palliative sedation.

DATA SOURCES AND REVIEW METHODS

A scoping review guided by Arksey and O`Malley`s methodological framework was used to analyze existing peer-reviewed empirical research on the topic of the practices and attitudes of nurses related to the palliative sedation of patients aged 18 years and older. Of the 316 publications identified from the PubMed, CINAHL and Cochrane Library, 17 full-text articles were included in this review. The data of the included articles were charted (author(s), year of publication, country, objectives, study design, data collection, setting, respondents, definition of palliative sedation, focus of the study and key findings), and the results were summarized with inductive content analysis. The PRISMA-ScR checklist was used as a guideline for the reporting in this review.

RESULTS

During the decision-making concerning the start of palliative sedation, nurses usually have an advocatory and supportive role, although the role varies between different countries. This role then changes to a relatively independent performance of sedation; including administration of the medication, monitoring the effectiveness of sedation, and in some cases taking decisions concerning the medication and dosage policy. Further, nurses provide information and compassionate care to both the patient and the family during the process of palliative sedation. Most nurses view palliative sedation as a positive and sometimes necessary last resort therapy to relieve refractory suffering of dying patients. However, sedation poses ethical problems for many nurses. These problems especially concern the essential elements of deciding to use palliative sedation, the depth of sedation, the potential for shortening life, and the loss of social interaction.

CONCLUSIONS

Nurses play a key role in palliative sedation, as they often perform sedation independently and have important information about the needs and wishes of both patients and their families due to their unique position at the bedside of the patient. Although nurses generally see palliative sedation as a positive practice for selected patients, many of them feel it is ethically controversial. This scoping review reveals a great need for further research and discussion on the practices and attitudes of nurses regarding palliative sedation.

Nurses' experiences of providing "sensitive nursing care" for terminally-ill individuals with cancer: A qualitative study

PURPOSE

To explore the sensitive nursing care provided by nurses who care for terminally-ill individuals with cancer.

METHODS

In-depth interviews were conducted using Colaizzi's phenomenological approach. Participants were 16 hospice specialists and four non-specialist nurses with experience in caring for terminal cancer patients in hospice specialized institutions in South Korea.

RESULTS

Eight theme clusters were drawn from the data and these clusters had two dimensions consisting of sensitive attitudes and sensitive nursing behaviors. The sensitive attitudes included reflecting on past experiences, developing an accepting attitude toward death, using intuition to address critical situations, and having an open mind regarding collaborating with colleagues. The sensitive nursing behaviors contained listening to patients' needs, responding to patients in a manner suitable to their conditions, quickly responding to patients' problem, and providing a moment saying farewell.

CONCLUSIONS

Teamwork and role models can help hospice specialists and non-specialist nurses caring for terminally-ill individuals with cancer to improve the sensitive nursing care. The sensitive attitudes and behaviors can be used as basic data for training programs designed to enhance nurses' sensitivity.

Moral identity and palliative sedation: A systematic review of normative nursing literature

Background:

In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care.

Research aim:

The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature.

Research design:

We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role.

Findings:

Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care.

Discussion and conclusion:

Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.