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Thomas C, Kulikowksi JD, Breitbart W, Alici Y, Bruera E, Blackler L, Sulmasy DP. Existential suffering as an indication for palliative sedation: Identifying and addressing challenges. Palliat Support Care 2024:1-4. [PMID: 38419195 PMCID: PMC11358359 DOI: 10.1017/s1478951524000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Julia D. Kulikowksi
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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Tan F, Li N, Wu Y, Zhang C. Palliative sedation determinants: systematic review and meta-analysis in palliative medicine. BMJ Support Palliat Care 2024; 13:e664-e675. [PMID: 37553203 PMCID: PMC10850834 DOI: 10.1136/spcare-2022-004085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The utilisation of palliative sedation is often favoured by patients approaching end of life due to the presence of multiple difficult-to-manage symptoms during the terminal stage. This study aimed to identify the determinants of the use of palliative sedation. METHODS To identify pertinent observational studies, a comprehensive search was performed in PubMed, Embase, Cochrane Library, and PsycINFO databases from their inception until March 2022. The methodological quality of the chosen prospective and retrospective cohort studies was assessed using the Newcastle Ottawa Scale, while the Agency for Healthcare Research and Quality was used to evaluate the methodological quality of the selected cross-sectional studies. For each potential determinant of interest, the collected data were synthesised and analysed, and in cases where data could not be combined, a narrative synthesis approach was adopted. RESULTS A total of 21 studies were analysed in this research, consisting of 4 prospective cohort studies, 7 retrospective cohort studies, and 10 cross-sectional studies. The findings indicated that several determinants were significantly associated with palliative sedation. These determinants included younger age, male gender, presence of tumours, dyspnoea, pain, delirium, making advanced medical end-of-life decisions, and dying in a hospital setting. CONCLUSIONS The findings of our review could help physicians identify patients who may need palliative sedation in advance and implement targeted interventions to reverse refractory symptoms, develop personalized palliative sedation programs, and ultimately improve the quality of palliative care services. TRIAL REGISTRATION PROSPERO registration number CRD42022324720.
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Affiliation(s)
- Fang Tan
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Na Li
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Wu
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuan Zhang
- Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Medicine Research Center, West China-PUMC C.C. Chen Institute of Health, West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
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Maeda S, Morita T, Yokomichi N, Imai K, Tsuneto S, Maeda I, Miura T, Ishiki H, Otani H, Hatano Y, Mori M. Continuous Deep Sedation for Psycho-Existential Suffering: A Multicenter Nationwide Study. J Palliat Med 2023; 26:1501-1509. [PMID: 37289183 DOI: 10.1089/jpm.2023.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Background: There is ongoing debate on whether continuous deep sedation (CDS) for psycho-existential suffering is appropriate. Objective: We aimed to (1) clarify clinical practice of CDS for psycho-existential suffering and (2) assess its impact on patients' survival. Methods: Advanced cancer patients admitted to 23 palliative care units in 2017 were consecutively enrolled. We compared patients' characteristics, CDS practices, and survival between those receiving CDS for psycho-existential suffering ± physical symptoms and only for physical symptoms. Results: Of 164 patients analyzed, 14 (8.5%) received CDS for psycho-existential suffering ± physical symptoms and only one of them (0.6%) solely for psycho-existential suffering. Patients receiving CDS for psycho-existential suffering, compared with those only for physical symptoms, were likely to have no specific religion (p = 0.025), and desired (78.6% vs. 22.0%, respectively; p < 0.001) and requested a hastened death more frequently (57.1% vs. 10.0%, respectively; p < 0.001). All of them had a poor physical condition with limited estimated survival, and mostly (71%) received intermittent sedation before CDS. CDS for psycho-existential suffering caused greater physicians' discomfort (p = 0.037), and lasted for longer (p = 0.029). Dependency, loss of autonomy, and hopelessness were common reasons for psycho-existential suffering that required CDS. The survival time after CDS initiation was longer in patients receiving it for psycho-existential suffering (log-rank, p = 0.021). Conclusion: CDS was applied to patients who suffered from psycho-existential suffering, which often associated with desire or request for a hastened death. Further studies and debate are warranted to develop feasible treatment strategies for psycho-existential suffering.
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Affiliation(s)
- Sayaka Maeda
- Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
- Research Association for Community Health, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Osaka, Japan
| | - Tomofumi Miura
- Department of Palliative Medicine, National Cancer Center Hospital East, Chiba, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Otani
- Department of Palliative and Supportive Care, St. Mary's Hospital, Fukuoka, Japan
- Department of Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Yutaka Hatano
- Department of Palliative Care, Daini Kyoritsu Hospital, Kawanishi, Japan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Mercadante S, Al-Husinat L. Palliative Care in Amyotrophic Lateral Sclerosis. J Pain Symptom Manage 2023; 66:e485-e499. [PMID: 37380145 DOI: 10.1016/j.jpainsymman.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/25/2023] [Accepted: 06/21/2023] [Indexed: 06/30/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease of the motor neurons. Given the evolutive characteristics of this disease, palliative care principles should be a foundation of ALS care. A multidisciplinary medical intervention is of paramount importance in the different phases of disease. The involvement of the palliative care team improves quality of life and symptoms, and prognosis. Early initiation is of paramount importance to ensuring patient-centered care, when the patient has still the capability to communicate effectively and participate in his medical care. Advance care planning supports patients and family members in understanding and sharing their preferences according to their personal values and life goals regarding future medical treatment. The principal problems which require intensive supportive care include cognitive disturbances, psychological distress, pain, sialorrhrea, nutrition, and ventilatory support. Communication skills of health-care professionals are mandatory to manage the inevitability of death. Palliative sedation has peculiar aspects in this population, particularly with the decision of withdrawing ventilatory support.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care (S.M.), La Maddalena Cancer Center, Palermo, Italy; Regional Home Care Program, SAMOT (S.M.), Palermo, Italy.
| | - Lou'i Al-Husinat
- Department of Clinical Medical Sciences (L.A.H.), Yarmouk University, Irbid, Jordan
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Lojo-Cruz C, Mora-Delgado J, Rivas Jiménez V, Carmona Espinazo F, López-Sáez JB. Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription. J Clin Med 2023; 12:5187. [PMID: 37629229 PMCID: PMC10455353 DOI: 10.3390/jcm12165187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.
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Affiliation(s)
- Cristina Lojo-Cruz
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Juan Mora-Delgado
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Víctor Rivas Jiménez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Fernando Carmona Espinazo
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerta del Mar, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Juan-Bosco López-Sáez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerto Real, Calle Romería 7, 11510 Puerto Real, Spain;
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Serey A, Tricou C, Phan-Hoang N, Legenne M, Perceau-Chambard É, Filbet M. Deep continuous patient-requested sedation until death: a multicentric study. BMJ Support Palliat Care 2023; 13:70-76. [PMID: 31005881 DOI: 10.1136/bmjspcare-2018-001712] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/18/2019] [Accepted: 02/27/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES In 2016, a new law was adopted in France granting patients the right, under specific conditions, to continuous deep sedation until death (CDSUD). The goal of this study was to measure the frequency of requests for CDSUD from patients in palliative care. METHODS The data collected from the medical records of patients in palliative care units (PCU) or followed by palliative care support teams (PCST) in the Rhône-Alpes area, who died after CDSUD, focused on the patient's characteristics, the drugs used (and compliance with regulatory processes). RESULTS All 12 PCU and 12 of the 24 PCST were included. Among the 8500 patients followed, 42 (0.5%) requested CDSUD until death. The patients were: 65.7 (SD=13.7) years old, highly educated (69%), had cancer (81%), refractory symptoms (98%) and mostly psychoexistential distress (69%). The request was rejected for 2 (5%) patients and delayed for 31 (74%) patients. After a delay of a mean 8 days, 13 (31%) patients were granted CDSUD. The drug used was midazolam at 115 mg/24 hours (15-480), during a mean of 3 days. PCUs used lower dosages than PCSTs (83 vs 147), with significantly lower initial doses (39 mg vs 132 mg, p=0.01). A life-threatening condition was recorded in 13 cases (31%) and a collegial decision was taken in 25 cases (60%). CONCLUSION This study highlights the low rate of request and the even lower rate of CDSUD in specialised palliative care. However, the sedation for psychoexistential distress and the lack of procedure records raise ethical questions.
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Affiliation(s)
- Adrien Serey
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | - Colombe Tricou
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | | | - Myriam Legenne
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
| | | | - Marilene Filbet
- Department of Palliative Care, Hospices Civils de Lyon, Lyon, France
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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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Abstract
BACKGROUND Existential distress is a widely used concept used in describing cancer patients. However, this concept is vague and has failed to achieve a consensus. The lack of a recognized conceptual framework could hinder future research on existential distress. OBJECTIVE The aim of this study was to clarify and analyze the concept of existential distress in cancer patients. METHODS The Walker and Avant concept analysis approach was applied. RESULTS For cancer patients, the concept of existential distress included 5 core attributes: (a) lack of meaning; (b) loss of autonomy; (c) loss of dignity; (d) hopelessness; and (e) death anxiety. Existential distress is a key factor causing poor quality of life, a poor emotional state, demoralization, and even suicide. It is often underpinned by uncontrolled physical pain, serious psychological morbidity, and a perceived sense of being a burden on others. CONCLUSION The concept analysis provides a theoretical framework for healthcare providers to better understand existential distress in cancer patients, to improve patient well-being. IMPLICATIONS FOR PRACTICE On the basis of the antecedents of this concept, cancer patients experiencing uncontrolled physical pain, severe psychological morbidity, and a perceived sense of being a burden on others are at a high risk of existential distress. These factors should be eliminated in a timely manner to prevent cancer patients from being caught in a state of existential distress. The 5 defining attributes and empirical referents of this concept could be used to develop tools to screen for existential distress in cancer patients and distinguish it from similar concepts.
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Abstract
Caring for patients who are dying is both a challenging and demanding role. This is further intensified by the expectation that in addition to attending to physical issues, nurses are expected to manage the emotional and psychological aspects of the situation. The inconsistent nature of the care pathways between differing specialist services can often mean that open access to specialist services is not possible. As such, staff may find themselves inadvertently supplementing and often reinforcing interventions offered by specialist (psychological) services with little consideration given to capacity, experience and resources. As the most ‘consistently present’ professionals in such settings, it is important for nursing colleagues to be aware of the emotional and psychological themes common to patients who are dying. Thus, allowing patients access to supportive conversation with professionals as and when required, ameliorating unnecessary distress.
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Affiliation(s)
- Feryad A Hussain
- Clinical Psychologist, Cancer and End-of-Life Services, Black Country Partnership NHS Foundation Trust, West Bromwich
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Ciancio AL, Mirza RM, Ciancio AA, Klinger CA. The Use of Palliative Sedation to Treat Existential Suffering: A Scoping Review on Practices, Ethical Considerations, and Guidelines. J Palliat Care 2019; 35:13-20. [DOI: 10.1177/0825859719827585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context: Though palliative sedation has been recognized as an acceptable practice in Canada for many years now, there is a lack of clinical research and guidelines pertaining to its use as a treatment of existential refractory symptoms in the terminally ill. Objectives: This scoping review aimed to survey the literature surrounding palliative sedation and existential suffering and to inform research, policy, and practice. Methods: To address the main research question: Is palliative sedation an acceptable intervention to treat existential refractory symptoms in adults aged 65 and older? a scoping review following Arksey and O’Malley’s framework was performed, spanning electronic databases of the peer reviewed and grey literature. Articles were screened for inclusion, and a thematic content analysis allowed for a summary of key findings. Results: Out of 427 search results, 71 full text articles were obtained, 20 of which were included. Out of these articles, four themes were identified as key findings. These included: (1) Ethical considerations; (2) The role of the health care provider; looking specifically at the impact on nurses; (3) The need for multidisciplinary care teams; and (4) Existential suffering’s connection to religiosity and spirituality. Conclusion: Palliative sedation to treat existential refractory symptoms was labelled a controversial practice. A shortage of evidence-based resources limits the current literature’s ability to inform policy and clinical practice. There is a need for both qualitative and quantitative multi-center research so health care professionals and regional-level institutions have firm roots to establish proper policy and practice.
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Affiliation(s)
- Allysa L. Ciancio
- Health Studies Program, University of Toronto, Toronto, Ontario, Canada
| | - Raza M. Mirza
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada
| | - Amy A. Ciancio
- Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Christopher A. Klinger
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
- National Initiative for the Care of the Elderly (NICE), Toronto, Ontario, Canada
- Translational Research Program, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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12
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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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Voeuk A, Nekolaichuk C, Fainsinger R, Huot A. Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views. J Palliat Care 2018; 32:26-33. [PMID: 28662627 DOI: 10.1177/0825859717711301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory. OBJECTIVES The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress. METHODS A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians. RESULTS Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone. CONCLUSION Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.
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Affiliation(s)
- Anna Voeuk
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl Nekolaichuk
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,2 Covenant Health Palliative Institute, Edmonton, Alberta, Canada
| | - Robin Fainsinger
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,2 Covenant Health Palliative Institute, Edmonton, Alberta, Canada
| | - Ann Huot
- 1 Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.,3 Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
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Abstract
Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.
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Affiliation(s)
| | | | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy.
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Bozzaro C, Schildmann J. "Suffering" in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice. J Pain Symptom Manage 2018; 56:288-294. [PMID: 29689298 DOI: 10.1016/j.jpainsymman.2018.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 11/19/2022]
Abstract
Palliative sedation is an increasingly used and, simultaneously, challenging practice at the end of life. Many controversies associated with this therapy are rooted in implicit differences regarding the understanding of "suffering" as a prerequisite for palliative sedation. The aim of this study is to inform the current debates by a conceptual analysis of two different philosophical accounts of suffering-1) the subjective and holistic concept and 2) the objective and gradual concept-and by a clinical-ethical analysis of the implications of each account for decisions about palliative sedation. We will show that although the subjective and holistic account of suffering fits well with the holistic approach of palliative care, there are considerable challenges to justify limits to requests for palliative sedation. By contrast, the objective and gradual account fits well with the need for an objective basis for clinical decisions in the context of palliative sedation but runs the risk of falling short when considering the individual and subjective experience of suffering at the end of life. We will conclude with a plea for the necessity of further combined conceptual and empirical research to develop a sound and feasible understanding of suffering, which can contribute to consistent decision making about palliative sedation.
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Affiliation(s)
- Claudia Bozzaro
- Department of Medical Ethics and History of Medicine, Albert-Ludwigs-University, Freiburg, Germany.
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Rodrigues P, Crokaert J, Gastmans C. Palliative Sedation for Existential Suffering: A Systematic Review of Argument-Based Ethics Literature. J Pain Symptom Manage 2018; 55:1577-1590. [PMID: 29382541 DOI: 10.1016/j.jpainsymman.2018.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
CONTEXT Although unanimity exists on using palliative sedation (PS) for controlling refractory physical suffering in end-of-life situations, using it for controlling refractory existential suffering (PS-ES) is controversial. Complicating the debate is that definitions and terminology for existential suffering are unclear, ambiguous, and imprecise, leading to a lack of consensus for clinical practice. OBJECTIVES To systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on PS-ES. METHODS We conducted a systematic search of the argument-based bioethics literature in PubMed, CINAHL, Embase®, The Philosopher's Index, PsycINFO®, PsycARTICLES®, Scopus, ScienceDirect, Web of Science, Pascal-Francis, and Cairn. We included articles published in peer-reviewed journals till December 31, 2016, written in English or French, which focused on ethical arguments related to PS-ES. We used Peer Review of Electronic Search Strategies protocol, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and The Qualitative Analysis Guide of Leuven for data extraction and synthesis of themes. RESULTS We identified 18 articles that met the inclusion criteria. Our analysis revealed mind-body dualism, existential suffering, refractoriness, terminal condition, and imminent death as relevant concepts in the ethical debate on PS-ES. The ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate. CONCLUSION There is a clear need to better define the terminology used in discussions of PS-ES and to ground ethical arguments in a more effective way. Anthropological presuppositions such as mind-body dualism underpin the debate and need to be more clearly elucidated using an interdisciplinary approach.
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Affiliation(s)
- Paulo Rodrigues
- Université Catholique de Lille, ETHICS EA7446, Centre for Medical Ethics, Lille, France; Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium; Université Catholique de Louvain, Research Institute Religions, Spirituality, Cultures, Societies (RSCS), Louvain-la-Neuve, Belgium.
| | - Jasper Crokaert
- Université Catholique de Louvain, Faculty of Medicine, Louvain-la-Neuve, Belgium
| | - Chris Gastmans
- Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Faculty of Medicine, Leuven, Belgium
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Johnson RJ. A research study review of effectiveness of treatments for psychiatric conditions common to end-stage cancer patients: needs assessment for future research and an impassioned plea. BMC Psychiatry 2018; 18:85. [PMID: 29614992 PMCID: PMC5883872 DOI: 10.1186/s12888-018-1651-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 03/07/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Rates of psychiatric conditions common to end-stage cancer patients (delirium, depression, anxiety disorders) remain unchanged. However, patient numbers have increased as the population has aged; indeed, cancer is a chief cause of mortality and morbidity in older populations. Effectiveness of psychiatric interventions and research to evaluate, inform, and improve interventions is critical to these patients' care. This article's intent is to report results from a recent review study on the effectiveness of interventions for psychiatric conditions common to end-stage cancer patients; the review study assessed the state of research regarding treatment effectiveness. Unlike previous review studies, this one included non-traditional/alternative therapies and spirituality interventions that have undergone scientific inquiry. METHODS A five-phase systematic strategy and a theoretic grounded iterative methodology were used to identify studies for inclusion and to craft an integrated, synthesized, comprehensive, and reasonably current end-product. RESULTS Psychiatric medication therapies undoubtedly are the most powerful treatments. Among them, the most effective (i.e., "best practices benchmarks") are: (1) for delirium, typical antipsychotics-though there is no difference between typical vs. atypical and other antipsychotics, except for different side-effect profiles, (2) for depression, if patient life expectancy is ≥4-6 weeks, then a selective serotonin reuptake inhibitor (SSRI), and if < 3 weeks, then psychostimulants or ketamine, and these generally are useful anytime in the cancer disease course, and (3) for anxiety disorders, bio-diazepams (BDZs) are most used and most effective. A universal consensus suggests that psychosocial (i.e., talk) therapy and spirituality interventions fortify the therapeutic alliance and psychiatric medication protocols. However, trial studies have had mixed results regarding effectiveness in reducing psychiatric symptoms, even for touted psychotherapies. CONCLUSIONS This study's findings prompted a testable linear conceptual model of co-factors and their importance for providing effective psychiatric care for end-stage cancer patients. The complicated and tricky part is negotiating patients' diagnoses while articulating internal intricacies within and between each of the model's co-factors. There is a relative absence of scientifically derived information and need for more large-scale, diverse scientific inquiry. Thus, this article is an impassioned plea for accelerated study and better care for end-stage cancer patients' psychiatric conditions.
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Affiliation(s)
- Ralph J Johnson
- Departments of Myeloma, TMC Catholic Chaplain's Corps, and Houston Hospice, University of Texas-MD Anderson Cancer Center, Unit 439, 1515 Holcombe Blvd, Houston, Texas, 77030, USA.
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van Deijck RH, Hasselaar JG, Krijnsen PJ, Gloudemans AJ, Verhagen SC, Vissers KC, Koopmans RT. The Practice of Continuous Palliative Sedation in Long-Term Care for Frail Patients with Existential Suffering. J Palliat Care 2017; 31:141-9. [DOI: 10.1177/082585971503100303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Some guidelines and recommendations identify existential suffering as a potential refractory symptom for which continuous palliative sedation (CPS) can be administered under certain conditions. However, there has been little research on the characteristics of patients with existential suffering treated with CPS and the degree to which the preconditions are fulfilled. The aim of this study was to provide insight into this specific indication for CPS. Questionnaires were sent to nursing home physicians in the Netherlands, who described 314 patients. Existential suffering was a refractory symptom in 83 of the patients. For most of the patients with refractory existential suffering, other refractory symptoms were also reported, and life expectancy was seven days or less; informed consent for initiating CPS had been obtained in all cases. Consultation and intermittent sedation before the start of CPS were far less frequently reported than one would expect based on the guidelines. Multivariate analysis showed that being male, having previously requested euthanasia, having a nervous system disease, or having an other diagnosis were positively correlated with the administration of CPS for existential suffering. We conclude that more attention should be paid to the suggested preconditions and to the presence of existential suffering in male patients or patients with a nervous system disease.
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Affiliation(s)
| | - Jeroen G.J. Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Petrus J.C. Krijnsen
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | | | - Stans C.A.H.H.V.M. Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kris C.P. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Raymond T.C.M. Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, Netherlands; and De Waalboog, Specialized Geriatric Care Centre Joachim en Anna, Nijmegen, Netherlands
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Cristina E, Carlo S, Gabriella D, Mirella P. Factors associated with the decision-making process in palliative sedation therapy. The experience of an Italian hospice struggling with balancing various individual autonomies. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1290307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Endrizzi Cristina
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
| | - Senore Carlo
- The Reference Centre for Epidemiology and Cancer Prevention, Regional Hospitals of City of Science and Health “AOU Città della Salute e della Scienza”, Turin, Italy
| | - D’Amico Gabriella
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
| | - Palella Mirella
- Hospice Il Gelso, Local Health Alessandria (ASL AL), Via San Pio V, 41, Alessandria, Italy
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Radha Krishna LK, Murugam V, Quah DSC. The practice of terminal discharge: Is it euthanasia by stealth? Nurs Ethics 2017; 25:1030-1040. [DOI: 10.1177/0969733016687155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
‘Terminal discharges’ are carried out in Singapore for patients who wish to die at home. However, if due diligence is not exercised, parallels may be drawn with euthanasia. We present a theoretical discussion beginning with the definition of terminal discharges and the reasons why they are carried out in Singapore. By considering the intention behind terminal discharges and utilising a multidisciplinary team to deliberate on the clinical, social and ethical intricacies with a patient- and context-specific approach, euthanasia is avoided. It is hoped that this will provide a platform for professionals in palliative medicine to negotiate challenging issues when arranging a terminal discharge, so as to avoid the pitfall of committing euthanasia in a country such as Singapore where euthanasia is illegal. It is hoped that a set of guidelines for terminal discharges may someday be realised to assist professionals in Singapore and around the world.
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Krishna LKR. Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach. JOURNAL OF BIOETHICAL INQUIRY 2015; 12:461-475. [PMID: 26173777 DOI: 10.1007/s11673-015-9651-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/09/2014] [Indexed: 06/04/2023]
Abstract
The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.
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Affiliation(s)
- Lalit Kumar Radha Krishna
- Department of Palliative Medicine, National Cancer Center Singapore, 11 Hospital Drive, Singapore, 169610, Singapore.
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Bozzaro C. Der Leidensbegriff im medizinischen Kontext: Ein Problemaufriss am Beispiel der tiefen palliativen Sedierung am Lebensende. Ethik Med 2015. [DOI: 10.1007/s00481-015-0339-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Rodriguez-Miranda R, Swetz KM, Hernández-Ortiz A, Strand JJ, Lara-Solares A, Hernández-Martinez EE, Tamayo-Valenzuela A, De la Fuente JR. Palliative sedation: Clinical practice challenges in Mexico and development of a national protocol for Mexico. PROGRESS IN PALLIATIVE CARE 2015. [DOI: 10.1179/1743291x15y.0000000001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Portnoy A, Rana P, Zimmermann C, Rodin G. The Use of Palliative Sedation to Treat Existential Suffering: A Reconsideration. PHILOSOPHY AND MEDICINE 2015. [DOI: 10.1007/978-94-017-9106-9_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
OBJECTIVE Hospice patients often struggle with loss of meaning, while many experience meaningful dreams. The purpose of this study was to conduct a preliminary exploration into the process and therapeutic outcomes of meaning-centered dream work with hospice patients. METHOD A meaning-centered variation of the cognitive-experiential model of dream work (Hill, 1996; 2004) was tested with participants. This variation was influenced by the tenets of meaning-centered psychotherapy (Breitbart et al., 2012). A total of 12 dream-work sessions were conducted with 7 hospice patients (5 women), and session transcripts were analyzed using the consensual qualitative research (CQR) method (Hill, 2012). Participants also completed measures of gains from dream interpretation in terms of existential well-being and quality of life. RESULTS Participants' dreams generally featured familiar settings and living family and friends. Reported images from dreams were usually connected to feelings, relationships, and the concerns of waking life. Participants typically interpreted their dreams as meaning that they needed to change their way of thinking, address legacy concerns, or complete unfinished business. Generally, participants developed and implemented action plans based on these interpretations, despite their physical limitations. Participants described dream-work sessions as meaningful, comforting, and helpful. High scores on a measure of gains from dream interpretation were reported, consistent with qualitative findings. No adverse effects were reported or indicated by assessments. SIGNIFICANCE OF RESULTS Our results provided initial support for the feasibility and helpfulness of dream work in this population. Implications for counseling with the dying and directions for future research were also explored.
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McKinnon M, Azevedo C, Bush SH, Lawlor P, Pereira J. Practice and documentation of palliative sedation: a quality improvement initiative. ACTA ACUST UNITED AC 2014; 21:100-3. [PMID: 24764700 DOI: 10.3747/co.21.1773] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative sedation (ps), the continuous use of sedating doses of medication to intentionally reduce consciousness and relieve refractory symptoms at end of life, is ethically acceptable if administered according to standards of best practice. Procedural guidelines outlining the appropriate use of ps and the need for rigorous documentation have been developed. As a quality improvement strategy, we audited the practice and documentation of ps on our palliative care unit (pcu). METHODS A pharmacy database search of admissions in 2008 identified, for a subsequent chart review, patients who had received either a continuous infusion of midazolam (≥10 mg/24 h), regular parenteral dosing of methotrimeprazine (≥75 mg daily), or regular phenobarbital. Documentation of the decision-making process, consent, and medication use was collected using a data extraction form based on current international ps standards. RESULTS Interpretation and comparison of data were difficult because of an apparent lack of a consistent operational definition of ps. Patient records had no specific documentation in relation to ps initiation, to clearly identified refractory symptoms, and to informed consent in 60 (64.5%), 43 (46.2%), and 38 (40.9%) charts respectively. Variation in the medications used was marked: 54 patients (58%) were started on a single agent and 39 (42%), on multiple agents. The 40 patients (43%) started on midazolam alone received a mean daily dose of 21.4 mg (standard deviation: 24.6 mg). CONCLUSIONS The lack of documentation and standardized practice of ps on our pcu has resulted in a quality improvement program to address those gaps. They also highlight the importance of conducting research and developing clinical guidelines in this area.
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Affiliation(s)
- M McKinnon
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON
| | - C Azevedo
- Department of Medical Oncology, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - P Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - J Pereira
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
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Palliative sedation for cancer patients included in a home care program: A retrospective study. Palliat Support Care 2014; 13:619-24. [DOI: 10.1017/s1478951514000200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AbstractObjective:Palliative sedation is a common treatment in palliative care. The home is a difficult environment for research, and there are few studies about sedation at home. Our aim was to analyze this practice in a home setting.Method:We conducted a retrospective cross-sectional descriptive study in a home cohort during 2011. The inclusion criteria were as follows: 18 years or older and enrolled in the Palliative Home Care Program (PHCP) with advanced cancer. The variables employed were: sex, age, primary tumor location, and place of death. We also registered indication, type, drug and dose, awareness of diagnosis and prognosis, consent, survival, presence or absence of rales, painful mouth, and ulcers in patients sedated at home. We also collected the opinions of family members and professionals about the suffering of sedated patients.Results:A total of 446 patients (56% at home) of the 617 admitted to the PHCP between January and December of 2011 passed away. The typical patient in our population was a 70-year-old man with a lung tumor. Some 35 (14%) home patients required sedation, compared to 93 (49%) at the hospital. The most frequent indication was delirium (70%), with midazolam the most common drug (mean dose, 40 mg). Survival was around three days. Rales were frequent (57%) as well as awareness of diagnosis and prognosis (77 and 71%, respectively). Perception of suffering after sedation was rare among relatives (17%) and professionals (8%). In most cases, the decision was made jointly by professionals and family members.Significance of Results:Our study confirmed the role of palliative sedation as an appropriate therapeutic tool in the home environment.
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Reid TT, Demme RA, Quill TE. When there are no good choices: illuminating the borderland between proportionate palliative sedation and palliative sedation to unconsciousness. Pain Manag 2014; 1:31-40. [PMID: 24654583 DOI: 10.2217/pmt.10.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite state-of-the-art palliative care, some patients will require proportionate palliative sedation as a last-resort option to relieve intolerable suffering at the end of life. In this practice, progressively increasing amounts of sedation are provided until the target suffering is sufficiently relieved. Uncertainty and debate arise when this practice approaches palliative sedation to unconsciousness (PSU), especially when unconsciousness is specifically intended or when the target symptoms are more existential than physical. METHODS We constructed a case series designed to highlight some of the common approaches and challenges associated with PSU and the more aggressive end of the spectrum of proportionate palliative sedation as retrospectively identified by palliative care consultants over the past 5 years from a busy inpatient palliative care service at a tertiary medical center in Rochester (NY, USA). RESULTS Ten cases were identified as challenging by the palliative care attendings, of which four were selected for presentation for illustrative purposes because they touched on central issues including loss of capacity, the role of existential suffering, the complexity of clinical intention, the role of an institutional policy and use of anesthetics as sedative agents. Two other cases were selected focusing on responses to two special situations: a request for PSU that was rejected; and anticipatory planning for total sedation in the future. CONCLUSION Although relatively rare, PSU and more aggressive end-of-the-spectrum proportionate palliative sedation represent responses to some of the most challenging cases faced by palliative care clinicians. These complex cases clearly require open communication and collaboration among caregivers, patients and family. Knowing how to identify these circumstances, and how to approach these interventions of last resort are critical skills for practitioners who take care of patients at the end of life.
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Affiliation(s)
- Thomas T Reid
- University of California, 533 Parnassus Avenue, Box 0903, Suite U154, San Francisco, CA 94143-0903, USA
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Affiliation(s)
- Mike Brady
- College of Human and Health Science, Swansea University, an associate lecturer with the Open University, and a paramedic with South Western Ambulance Service NHS Foundation Trust
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[Palliative sedation for psycho-existential suffering]. Wien Med Wochenschr 2013; 164:172-8. [PMID: 24158418 DOI: 10.1007/s10354-013-0246-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 10/07/2013] [Indexed: 10/26/2022]
Abstract
Sedation in palliative care is generally considered as an important therapy in terminally ill patients with refractory symptoms. However the sedation of patients with intractable psycho-existential suffering is still under discussion. This paper discusses the case of a 56-year-old patient in the final phase of carcinoma of the ovaries, who required palliative sedation for refractory, mainly psycho-existential suffering. It describes the course on our ward and the difficult process of decision-making. We discuss our approach based on literature.
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Abstract
Palliative care psychiatry is an emerging subspecialty field at the intersection of Palliative Medicine and Psychiatry. The discipline brings expertise in understanding the psychosocial dimensions of human experience to the care of dying patients and support of their families. The goals of this review are (1) to briefly define palliative care and summarize the evidence for its benefits, (2) to describe the roles for psychiatry within palliative care, (3) to review recent advances in the research and practice of palliative care psychiatry, and (4) to delineate some steps ahead as this sub-field continues to develop, in terms of research, education, and systems-based practice.
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Affiliation(s)
- Nathan Fairman
- Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, Sacramento, CA, USA.
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French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering. Palliat Support Care 2013; 12:345-50. [PMID: 23768798 DOI: 10.1017/s1478951513000278] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). METHODS We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. RESULTS 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.
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Dirksen KM, Hynds JA, Bhavsar AR, Brown-Saltzman K. The existential question in palliative sedation: reply to Putman et al. J Pain Symptom Manage 2013; 45:e1-2. [PMID: 23523359 DOI: 10.1016/j.jpainsymman.2012.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 12/23/2012] [Indexed: 11/29/2022]
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Mah L, Grief C, Grossman D, Rootenberg M. Assessment of Patient Dignity in Geriatric Palliative Care. J Am Geriatr Soc 2012; 60:2178-80. [DOI: 10.1111/j.1532-5415.2012.04235.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Linda Mah
- Rotman Research Institute; Baycrest; Toronto Ontario Canada
- Department of Psychiatry; Baycrest; Toronto Ontario Canada
- Division of Geriatric Psychiatry; Department of Psychiatry; University of Toronto; Toronto Ontario Canada
| | - Cindy Grief
- Department of Psychiatry; Baycrest; Toronto Ontario Canada
- Division of Geriatric Psychiatry; Department of Psychiatry; University of Toronto; Toronto Ontario Canada
| | - Daphna Grossman
- Department of Family and Community Medicine; Baycrest; Toronto Ontario Canada
- Division of Palliative Care; Department of Family and Community Medicine; University of Toronto; Toronto Ontario Canada
| | - Mark Rootenberg
- Department of Family and Community Medicine; Baycrest; Toronto Ontario Canada
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Dean MM, Cellarius V, Henry B, Oneschuk D, Librach (Canadian Society of Pallia SL. Framework for Continuous Palliative Sedation Therapy in Canada. J Palliat Med 2012; 15:870-9. [DOI: 10.1089/jpm.2011.0498] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mervyn M. Dean
- Palliative Care, Western Memorial Regional Hospital, Corner Brook, Newfoundland and Labrador, Canada
| | - Victor Cellarius
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Blair Henry
- Ethics Centre, Sunnybrook Health Sciences Centre, Department of Family and Community Medicine, University of Toronto, University of Toronto, Toronto, Ontario, Canada
- Joint Centre for Bioethics, University of Toronto, Ontario, Canada
| | - Doreen Oneschuk
- Edmonton Regional Palliative Care Program, Grey Nuns Hospital, Edmonton, Alberta, Canada
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36
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Hahn MP. Review of palliative sedation and its distinction from euthanasia and lethal injection. J Pain Palliat Care Pharmacother 2012; 26:30-9. [PMID: 22448939 DOI: 10.3109/15360288.2011.650353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.
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Affiliation(s)
- Michael P Hahn
- Respiratory Care, Loma Linda University Children's Hospital, Loma Linda, California 92354, USA.
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37
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Billings JA, Churchill LR. Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature? J Palliat Med 2012; 15:709-13. [DOI: 10.1089/jpm.2011.0157] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J. Andrew Billings
- Cambridge Health Alliance, Cambridge, Massachusetts, and Massachusetts General Hospital and the Harvard Medical School Center for Palliative Care, Boston, Massachusetts
| | - Larry R. Churchill
- Ann Geddes Stahlman Professor of Medical Ethics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
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38
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La recherche de sens en oncologie : fondements théoriques et application clinique de la logothérapie. PSYCHO-ONCOLOGIE 2012. [DOI: 10.1007/s11839-012-0365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Berger JT. Preemptive use of palliative sedation and amyotrophic lateral sclerosis. J Pain Symptom Manage 2012; 43:802-5. [PMID: 22464355 DOI: 10.1016/j.jpainsymman.2011.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 10/27/2011] [Accepted: 11/01/2011] [Indexed: 10/28/2022]
Abstract
Patients in the advanced stages of amyotrophic lateral sclerosis often are faced with the dilemma of whether to use or continue to use mechanical ventilation. Patients who elect to terminate ventilatory support may be subject to significant and even extreme respiratory symptoms. Severe dyspnea and other symptoms are sometimes treated with palliative sedation, which is generally recommended as a last resort approach to refractory symptoms. However, the preemptive use of palliative sedation is sometimes appropriate. The preemptive use of palliative sedation is examined through a case-based analysis of a patient with advanced amyotrophic lateral sclerosis.
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Affiliation(s)
- Jeffrey T Berger
- Hospice and Palliative Medicine, Division of Geriatric Medicine, and Clinical Ethics, Department of Medicine, Winthrop University Hospital, Mineola, NY, USA.
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40
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Abstract
AbstractDespite significant improvement in cancer survival, the fear of death still remains rooted in individuals' beliefs about cancer. Existential fears pertaining to cancer cut across the cancer control continuum and taint decisions related to prevention, screening, surveillance, and follow-up recommendations, as well as the overall management of cancer-related issues. However, individuals are innately predisposed to cope with their cancer-related fears through mechanisms such as reliance on the process of meaning making. To better appreciate the potential impact of existential concerns across the cancer control continuum, the Temporal Existential Awareness and Meaning Making (TEAMM) model is proposed. This tripartite model depicts three types of perceived threats to life related to cancer including a “social awareness” (i.e., cancer signals death), “personalized awareness” (i.e., I could die from cancer), and the “lived experience” (i.e., It feels like I am dying from cancer). This construal aims to enhance our understanding of the personal and contextual resources that can be mobilized to manage existential concerns and optimize cancer control efforts. As such, existential discussions should be considered in any cancer-related supportive approach whether preventive, curative, or palliative, and not be deferred only until the advanced stages of cancer or at end of life. Further delineation and validation of the model is needed to explicitly recognize and depict how different levels of existential awareness might unfold as individuals grapple with a potential, actual, or recurrent cancer.
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41
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Prospective observational Italian study on palliative sedation in two hospice settings: differences in casemixes and clinical care. Support Care Cancer 2012; 20:2829-36. [DOI: 10.1007/s00520-012-1407-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 02/06/2012] [Indexed: 10/28/2022]
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42
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Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage 2011; 41:604-18. [PMID: 21145202 DOI: 10.1016/j.jpainsymman.2010.05.010] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 11/29/2022]
Abstract
CONTEXT Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade. OBJECTIVES To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions. METHODS A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care. RESULTS The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood. CONCLUSION Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.
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Affiliation(s)
- Patricia Boston
- Division of Palliative Care, Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.
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Sudore RL, Villars P, Carey EC. Sitting with You in Your Suffering: Lessons about Intractable Pain at the End of Life. J Palliat Med 2010; 13:779-82. [DOI: 10.1089/jpm.2009.0325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
| | - Patrice Villars
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California
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Kirk TW, Mahon MM. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manage 2010; 39:914-23. [PMID: 20471551 DOI: 10.1016/j.jpainsymman.2010.01.009] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 01/04/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Timothy W Kirk
- Department of History & Philosophy, City University of New York-York College, Jamaica, New York 11451, USA.
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Cassell EJ, Rich BA. Intractable end-of-life suffering and the ethics of palliative sedation. PAIN MEDICINE 2010; 11:435-8. [PMID: 20088855 DOI: 10.1111/j.1526-4637.2009.00786.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Palliative sedation (sedation to unconsciousness) as an option of last resort for intractable end-of-life distress has been the subject of ongoing discussion and debate as well as policy formulation. A particularly contentious issue has been whether some dying patients experience a form of intractable suffering not marked by physical symptoms that can reasonably be characterized as "existential" in nature and therefore not an acceptable indication for palliative sedation. Such is the position recently taken by the American Medical Association. In this essay we argue that such a stance reflects a fundamental misunderstanding of the nature of human suffering, particularly at the end of life, and may deprive some dying patients of an effective means of relieving their intractable terminal distress.
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Rady MY, Verheijde JL. Continuous Deep Sedation Until Death: Palliation or Physician-Assisted Death? Am J Hosp Palliat Care 2009; 27:205-14. [DOI: 10.1177/1049909109348868] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Published literature have not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (ie, dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.
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Affiliation(s)
- Mohamed Y. Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona, , School of Life Sciences, Bioethics, Policy, and Law Program, Arizona State University, Tempe, Arizona
| | - Joseph L. Verheijde
- Department of Biomedical Ethics, Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona, School of Life Sciences, Bioethics, Policy, and Law Program, Arizona State University, Tempe, Arizona
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