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Prampart S, Huon JF, Colpaert A, Delavaud C, Nizard J, Evin A. Deep continuous sedation at the patient's request until death in a palliative care unit: retrospective study. BMJ Support Palliat Care 2024; 14:60-64. [PMID: 37696585 DOI: 10.1136/spcare-2023-004551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Limited descriptive data are available on continuous and deep sedation maintained until death (CDSUD) at the patient's request in palliative care units. This study aimed to describe such practices in the context of refractory suffering or after a request to stop life-sustaining treatment, evaluating the duration and dosage of sedative treatments used. METHODS This retrospective observational study included consecutively hospitalised patients in a palliative care unit from January 2020 to December 2021. Data on patient profiles, reasons for the sedation request, duration of sedation and doses of sedatives were collected. RESULTS Among 42 patients who underwent CDSUD, 79% occurred due to refractory suffering. In cases of sedation following a request to stop life support, high-dose corticosteroid therapy was the most commonly involved life-sustaining treatment. Midazolam was always the first-line sedative treatment. Chlorpromazine was added in 79% of cases, and propofol in 40%, to achieve a deep level of sedation. The mean maximum doses of midazolam, chlorpromazine and propofol were 7.6 mg/hour (±1.9), 3.3 mg/hour (±0.9) and 1.7 mg/kg/hour, respectively. The average duration of sedation was 37 hours. CONCLUSIONS This study provides new descriptive elements on CDSUD. Notably, it highlights the use of second-line sedative molecules, such as propofol.
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Affiliation(s)
- Simon Prampart
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Jean Francois Huon
- CHU de Nantes, Pharmacie, Nantes Université, Nantes, France
- INSERM UMR 1246 SPHERE, Nantes Université, Nantes, France
| | - Andre Colpaert
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Clémence Delavaud
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
| | - Julien Nizard
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
- EA4391 Therapeutic and Nervous Excitability, Universite Paris-Est Creteil Val de Marne, Creteil, France
| | - Adrien Evin
- CHU de Nantes, Service de Soins Palliatifs et de Support, Nantes Université, Nantes, France
- INSERM UMR 1246 SPHERE, Nantes Université, Nantes, France
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Frasca M, Jonveaux T, Lhuaire Q, Bidegain-Sabas A, Chanteclair A, Francis-Oliviero F, Burucoa B. Sedation practices in palliative care services across France: a nationwide point-prevalence analysis. BMJ Support Palliat Care 2024; 13:e1326-e1334. [PMID: 37463761 PMCID: PMC10850836 DOI: 10.1136/spcare-2023-004261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/30/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service. METHODS We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study. RESULTS In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type. CONCLUSIONS This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices.
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Affiliation(s)
- Matthieu Frasca
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | - Thérèse Jonveaux
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Quentin Lhuaire
- Unité Méthodes d'Evaluation en Santé (UMES), University Hospital of Bordeaux, Bordeaux, France
| | - Adèle Bidegain-Sabas
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
| | - Alex Chanteclair
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France
| | | | - Benoît Burucoa
- Palliative Care Department, University Hospital Centre Bordeaux, Bordeaux, France
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3
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Le Dorze M, Barthélémy R, Giabicani M, Audibert G, Cousin F, Gakuba C, Robert R, Chousterman B, Perrigault PF. Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey. Palliat Med 2023; 37:1202-1209. [PMID: 37306034 DOI: 10.1177/02692163231180656] [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] [Indexed: 06/13/2023]
Abstract
BACKGROUND Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs). AIM The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting. DESIGN AND SETTING French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies. RESULTS A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5-18] mg h-1) and propofol (200 [120-250] mg h -1). The Richmond Agitation Sedation Scale (RASS) was -5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices (n = 98), medicines doses were higher with no difference in the depth of sedation. CONCLUSIONS This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université Paris-Saclay, CESP U1018, Inserm, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Mikhael Giabicani
- Department of Anaesthesia and Critical Care, AP-HP, Beaujon Hospital, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, Laboratoire ETREs, Paris, France
| | - Gérard Audibert
- Department of Anaesthesia and Critical Care Medicine, CHRU Nancy, Université de Lorraine, Nancy, France
| | - François Cousin
- Centre national des soins palliatifs et de la fin de vie (CNSPFV), Paris, France
| | - Clément Gakuba
- Department of Anesthesia and Critical Care Medicine, Caen, France
| | - René Robert
- Médecine Intensive Réanimation, CHU Poitiers, F-86000, Poitiers, France
- Université de Poitiers, CIC Inserm ALIVE, F-86000, Poitiers, France
| | - Benjamin Chousterman
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Pierre-François Perrigault
- Department of Anesthesia and Critical Care Medicine, Gui de Chauliac University Hospital, Université de Montpellier, Montpellier, France
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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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Klein C, Voss R, Ostgathe C, Ansgar Schildmann J. Sedation in Palliative Care—a Clinically Oriented Overview of Guidelines and Treatment Recommendations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:235-242. [PMID: 36851822 PMCID: PMC10282508 DOI: 10.3238/arztebl.m2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 08/29/2022] [Accepted: 02/02/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The appropriate provision of sedation as a last resort for the relief of suffering in palliative care is dealt with variably in actual practice. This article is intended as an overview of practically relevant information found in treatment recommendations and guidelines. METHODS A systematic literature search was conducted in the PubMed, Scopus, and Google Scholar databases, and a manual search was carried out online. Recommendations that were not available in either German or English, or that were specific to pediatric practice, were excluded. Publication quality was assessed with the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II). The recommendations in the documents were qualitatively evaluated. RESULTS 29 publications (11 journal articles, 18 other) of varying quality according to AGREE II were included. All recommendations and guidelines were essentially based on expert consensus. The common indications for sedation are otherwise intractable delirium, dyspnea, and pain, in patients with a life expectancy of no more than two weeks. Existential distress is a controversial indication. The drug of first choice is midazolam. As the sedating effect of opioids is hard to predict, they should not be used as sedatives. The risks of sedation include respiratory and circulatory depression, as well as the loss of communicative ability, control, and autonomy. It is generally recommended that the patient's symptom burden and depth of sedation should be monitored; clinical and technically supported monitoring are recommended in some publications as well, depending on the situation. CONCLUSION There is a broad consensus in favor of sedation to relieve suffering in the last days and hours of life. Recommendations vary for patients with a longer life expectancy and for those with existential distress, and with respect to monitoring.
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Affiliation(s)
- Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg
| | - Rafaela Voss
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg
| | - Christoph Ostgathe
- Department of Palliative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg
| | - Jan Ansgar Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg
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6
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Ridley A, Vial-Cholley E, Robert G, Jounis-Jahan F, Lervat C, Betremieux P, Viallard ML, Frache S, Cojean N. Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams. J Pain Symptom Manage 2023; 65:308-317. [PMID: 36528187 DOI: 10.1016/j.jpainsymman.2022.12.006] [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: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families. OBJECTIVES Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. METHODS We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. RESULTS Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. CONCLUSION Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.
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Affiliation(s)
- Ashley Ridley
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France.
| | | | - Guillaume Robert
- Pediatric Palliative Care Team Bretagne (G.R.), Rennes, France; University of Rennes 1 (G.R.), Rennes, France
| | | | - Cyril Lervat
- Pediatric Palliative Care Team Hauts de France (C.L.), Lille, France; Pediatric, Adolescent and Young Adult Oncology Unit (C.L.), Oscar Lambret Centre, Lille, France
| | - Pierre Betremieux
- French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Marcel-Louis Viallard
- Necker Enfants Malades Children's Hospital, Pediatric Palliative Care Team (A.R., M.L.V.), Paris, France
| | - Sandra Frache
- Pediatric Palliative Care Team Franche-Comté (S.F.), Besançon, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
| | - Nadine Cojean
- Pediatric Palliative Care Team Alsace (N.C.), Strasbourg, France; French Society of Pediatric Palliative Care, Société Française de Soins Palliatifs Pédiatriques (P.B., S.F., N.C.)
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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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Lee SH, Kwon JH, Won YW, Kang JH. Palliative Sedation in End-of-Life Patients in Eastern Asia: A Narrative Review. Cancer Res Treat 2022; 54:644-650. [PMID: 35436813 PMCID: PMC9296933 DOI: 10.4143/crt.2022.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/17/2022] [Indexed: 11/21/2022] Open
Abstract
Although palliative sedation (PS) is a common practice in the palliative care of cancer patients in Western countries, there is little related research on the practice in Korea. PS can be classified into several categories according to sedation level and continuity. PS is clearly distinct from euthanasia. While euthanasia is illegal and regarded as unethical in Korea, there is little ethical and legal controversy about PS in terms of the doctrine of double effect. Most studies have asserted that PS does not shorten the survival of terminal cancer patients. Since preference for PS heavily depends on stakeholder value, it should be preceded by shared decision-making through full communication among the patient, family members, and medical team. This is a narrative review article analyzing previous studies, especially from the three Eastern Asian countries, Korea, Japan and Taiwan, which share similar cultures compared with Western countries. Practical issues concerning PS—for example, prevalence, type and dosage of medications, salvage medication, timing of its initiation, and assessment—are described in detail.
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Affiliation(s)
- Seung Hun Lee
- Department of Family Medicine, Pusan National University Hospital, Busan, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, College of Medicine, Chungnam National University, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Young-Woong Won
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
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Ana Soeiro ACVS, Victor de Souza Vasconcelos, Thalita da Rocha Bastos. Sedação Paliativa, Bioética e Terminalidade da Vida. REVISTA IBEROAMERICANA DE BIOÉTICA 2022. [DOI: 10.14422/rib.i18.y2022.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A humanização vem ganhando ampla repercussão no campo da ética médica, apontando a importância dos Cuidados Paliativos e da sedação paliativa quando a morte se revela uma imponderável realidade. O artigo visa estimular a reflexão bioética sobre a sedação paliativa, considerando as discussões contemporâneas sobre o morrer com dignidade. Trata-se de um estudo exploratório e descritivo, com participação de médicos/as de um hospital oncológico. Os achados demonstram que a sedação paliativa auxilia o manejo da dor e do sofrimento, entretanto, é necessária a intensificação das discussões sobre o tema, incluindo maior participação de pacientes nas decisões médicas.
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Ahn HK, Ahn HY, Park SJ, Hwang IC. Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:254-260. [PMID: 37674644 PMCID: PMC10180067 DOI: 10.14475/jhpc.2021.24.4.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/30/2021] [Indexed: 09/08/2023]
Abstract
Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.
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Affiliation(s)
- Hee Kyung Ahn
- Oncology Division, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Hong Yup Ahn
- Department of Statistics, Dongguk University, Seoul, Korea
| | | | - In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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11
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Tham K, Shiu A, William L, Walpole G, Rashed S. Refractory hyperactive delirium in the dying: pharmacological management. BMJ Support Palliat Care 2021; 12:471-474. [PMID: 34819327 DOI: 10.1136/bmjspcare-2021-003139] [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: 04/24/2021] [Accepted: 10/21/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delirium is a prevalent clinical presentation in advanced illness. The hyperactive phase can cause severe symptoms at the end of life. There is no published study of the pharmacological management of this symptom in Australian palliative medicine practice. OBJECTIVES To describe the pharmacological management of hyperactive delirium at the end of life in an Australian inpatient palliative care setting. METHODS Retrospective audit of deaths from October 2019 where a medication of interest (MOI) was used following admission to the palliative care unit (PCU) of Eastern Health. The clinical notes of those included were reviewed to further describe the clinical details surrounding the use of the MOI. RESULTS Forty patients were included. Midazolam was the most common medication used (57.5%). The most common dual agent combination was midazolam plus levomepromazine. CONCLUSIONS This audit is the first description of pharmacological management of severe hyperactive delirium at the end of life requiring sedation in an Australian PCU.
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Affiliation(s)
- Kathryn Tham
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Angela Shiu
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia .,Pharmacy Department, Eastern Health, Wantirna, VIC, Australia
| | - Leeroy William
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia.,Public Health Palliative Care Unit, Latrobe University, Melbourne, VIC, Australia
| | - Grace Walpole
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Saly Rashed
- Supportive and Palliative Care Service, Wantirna Health, Wantirna, VIC, Australia.,Pharmacy Department, Eastern Health, Wantirna, VIC, Australia
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12
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Ashraf MW, Uusalo P, Scheinin M, Saari TI. Population Modelling of Dexmedetomidine Pharmacokinetics and Haemodynamic Effects After Intravenous and Subcutaneous Administration. Clin Pharmacokinet 2021; 59:1467-1482. [PMID: 32462542 PMCID: PMC7658092 DOI: 10.1007/s40262-020-00900-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Objective Dexmedetomidine is a potent agonist of α2-adrenoceptors causing dose-dependent sedation in humans. Intravenous dexmedetomidine is commonly used perioperatively, but an extravascular route of administration would be favoured in palliative care. Subcutaneous infusions provide desired therapeutic plasma concentrations with fewer unwanted effects as compared with intravenous dosing. We aimed to develop semi-mechanistic population models for predicting pharmacokinetic and pharmacodynamic profiles of dexmedetomidine after intravenous and subcutaneous dosing. Methods Non-linear mixed-effects modelling was performed using previously collected concentration and haemodynamic effects data from ten (eight in the intravenous phase) healthy human subjects, aged 19–27 years, receiving 1 µg/kg of intravenous or subcutaneous dexmedetomidine during a 10-min infusion. Results The absorption of dexmedetomidine from the subcutaneous injection site, and distribution to local subcutaneous fat tissue was modelled using a semi-physiological approach consisting of a depot and fat compartment, while a two-compartment mammillary model explained further disposition. Dexmedetomidine-induced reductions in plasma norepinephrine concentrations were accurately described by an indirect response model. For blood pressure models, the net effect was specified as hyper- and hypotensive effects of dexmedetomidine due to vasoconstriction on peripheral arteries and sympatholysis mediated via the central nervous system, respectively. A heart rate model combined the dexmedetomidine-induced sympatholytic effect, and input from the central nervous system, predicted from arterial blood pressure levels. Internal evaluation confirmed the predictive performance of the final models, as well as the accuracy of the parameter estimates with narrow confidence intervals. Conclusions Our final model precisely describes dexmedetomidine pharmacokinetics and accurately predicts dexmedetomidine-induced sympatholysis and other pharmacodynamic effects. After subcutaneous dosing, dexmedetomidine is taken up into subcutaneous fat tissue, but our simulations indicate that accumulation of dexmedetomidine in this compartment is insignificant. ClinicalTrials.org NCT02724098 and EudraCT 2015-004698-34 Electronic supplementary material The online version of this article (10.1007/s40262-020-00900-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad W Ashraf
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland.,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Mika Scheinin
- Institute of Biomedicine, University of Turku, Turku, Finland.,Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
| | - Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Kiinamyllynkatu 4-8 (11A5), P.O. Box 52, 20521, Turku, Finland. .,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
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13
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Fredheim OM, Skulberg IM, Magelssen M, Steine S. Clinical and ethical aspects of palliative sedation with propofol-A retrospective quantitative and qualitative study. Acta Anaesthesiol Scand 2020; 64:1319-1326. [PMID: 32632937 DOI: 10.1111/aas.13665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The anesthetic propofol is often mentioned as a drug that can be used in palliative sedation. The existing literature of how to use propofol in palliative sedation is scarce, with lack of information about how propofol could be initiated for palliative sedation, doses and treatment outcomes. AIM To describe the patient population, previous and concomitant medication, and clinical outcome when propofol was used for palliative sedation. METHODS A retrospective study with quantitative and qualitative data. All patients who during a 4.5-year period received propofol for palliative sedation at the Department of palliative medicine, Akershus University Hospital, Norway were included. RESULTS Fourteen patients were included. In six patients the main indication for palliative sedation was pain, in seven dyspnoea and in one delirium. In eight of these cases propofol was chosen because of the pharmacokinetic properties (rapid effect), and in the remaining cases propofol was chosen because midazolam in spite of dose titration failed to provide sufficient symptom relief. In all patients sedation and adequate symptom control was achieved during manual dose titration. During the maintenance phase three of 14 patients had spontaneous awakenings. At death, propofol doses ranged from 60 to 340 mg/hour. CONCLUSIONS Severe suffering at the end of life can be successfully treated with propofol for palliative sedation. This can be performed in palliative medicine wards, but skilled observation and dose titration throughout the period of palliative sedation is necessary. Successful initial sedation does not guarantee uninterrupted sedation until death. EDITORIAL COMMENT In palliative care, some patients at the end of life can reach a stage where there have been maximal analgesic and or anxiolytic treatments though without achieving comfort in the awake state. This report describes and discusses use of propofol in these infrequent cases to relieve suffering as part of palliative care.
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Affiliation(s)
- Olav M. Fredheim
- Department of Palliative Medicine Akershus University Hospital Lørenskog Norway
- Department of Circulation and Medical Imaging Faculty of Medicine Norwegian University of Science and Technology Trondheim Norway
- National Competence Centre for Complex Symptom Disorders Department of Pain and Complex Disorders St. Olavs Hospital Trondheim Norway
| | | | - Morten Magelssen
- Centre for Medical Ethics Institute of Health and Society University of Oslo Oslo Norway
| | - Siri Steine
- Department of Palliative Medicine Akershus University Hospital Lørenskog Norway
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14
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Gruenewald DA, Vandekieft G. Options of Last Resort: Palliative Sedation, Physician Aid in Dying, and Voluntary Cessation of Eating and Drinking. Med Clin North Am 2020; 104:539-560. [PMID: 32312414 DOI: 10.1016/j.mcna.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Some patients with terminal and degenerative illnesses request assistance to hasten death when suffering is refractory to palliative care, or they strongly desire to maximize their autonomy and dignity and minimize suffering. Palliative sedation (PS), voluntarily stopping eating and drinking (VSED), and physician-assisted death (PAD) are possible options of last resort. A decision to choose PS can be made by an informed surrogate decision maker, whereas intact decision-making capacity is required to choose VSED or PAD. For all palliative treatments of last resort, the risk of harm is minimized by the use of checklists, and establishment of policies and procedures.
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Affiliation(s)
- David A Gruenewald
- Palliative Care and Hospice Service, Geriatrics and Extended Care Service, Veterans Affairs Puget Sound Healthcare System, (S-182-GEC), 1660 South Columbian Way, Seattle, WA 98108, USA; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Gregg Vandekieft
- Palliative Care Program, Providence St. Joseph Health Southwest Washington Region, Providence St. Peter Hospital, 413 Lilly Road Northeast, Olympia, WA 98506, USA; Palliative Practice Group, Institute for Human Caring at Providence St. Joseph Health, 879 W. 190th St., Suite 1000, Gardena, CA 90248, USA; Department of Family Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA. https://twitter.com/vandekieftg
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15
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Robert R, Le Gouge A, Kentish-Barnes N, Adda M, Audibert J, Barbier F, Bourcier S, Bourenne J, Boyer A, Devaquet J, Grillet G, Guisset O, Hyacinthe AC, Jourdain M, Lerolle N, Lesieur O, Mercier E, Messika J, Renault A, Vinatier I, Azoulay E, Thille AW, Reignier J. Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study. Intensive Care Med 2020; 46:1194-1203. [PMID: 31996960 DOI: 10.1007/s00134-020-05930-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/10/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation. METHODS Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death. RESULTS Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. CONCLUSION Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.
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Affiliation(s)
- Rene Robert
- Université de Poitiers, Poitiers, France. .,Inserm CIC 1402, ALIVE, Poitiers, France. .,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | | | - Nancy Kentish-Barnes
- Service de Médecine Intensive Réanimation, Groupe de Recherche Famiréa, CHU Saint-Louis, Paris, France
| | - Mélanie Adda
- APHM, URMITE, UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Université, Marseille, France
| | - Juliette Audibert
- Service de Réanimation Polyvalente, CH de Chartres, Chartres, France
| | | | - Simon Bourcier
- Université Paris-Descartes, Paris, France.,Service de Médecine Intensive Réanimation, Assistance Publique des Hôpitaux de Paris, CHU Cochin, Paris, France
| | - Jeremy Bourenne
- APHM, Hôpital La Timone, Réanimation et surveillance continue, Aix-Marseille Université, Marseille, France
| | - Alexandre Boyer
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Bordeaux, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Guillaume Grillet
- CH Bretagne Sud, Service de Réanimation Polyvalente, Lorient, France
| | - Olivier Guisset
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Hôpital Saint-André, Bordeaux, France
| | - Anne-Claire Hyacinthe
- Service de Réanimation Polyvalente, Centre Hospitalier Annecy Genevois, Pringy, France
| | - Mercé Jourdain
- Université de Lille, Lille, France.,Service de Réanimation Polyvalente, Inserm U1190, CHRU de Lille - Hôpital Roger Salengro, Lille, France
| | - Nicolas Lerolle
- Université d'Angers, Angers, France.,Département de Réanimation médicale et Médecine hyperbare, CHU Angers, Angers, France
| | - Olivier Lesieur
- Service de Réanimation Polyvalente, CH de La Rochelle, La Rochelle, France
| | - Emmanuelle Mercier
- Université de Tours, Tours, France.,CHU de Tours, Service de Médecine Intensive Réanimation, Hôpital Bretonneau, Tours, France.,Réseau CRICS, Tours, France
| | - Jonathan Messika
- APHP; Nord-Université de Paris, Service de Réanimation médico-chirurgicale, Hôpital Louis Mourier, Colombes; Inserm U 1137, Paris, France, Colombes, France
| | - Anne Renault
- Université de Bretagne Occidentale, Brest, France.,Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France
| | - Isabelle Vinatier
- Service de Réanimation Polyvalente, CHD de la Vendée, La Roche-sur-Yon, France
| | - Elie Azoulay
- Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Arnaud W Thille
- Université de Poitiers, Poitiers, France.,Inserm CIC 1402, ALIVE, Poitiers, France.,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Jean Reignier
- Université de Nantes, Nantes, France.,Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
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16
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Prommer E. Midazolam: an essential palliative care drug. Palliat Care Soc Pract 2020; 14:2632352419895527. [PMID: 32215374 PMCID: PMC7065504 DOI: 10.1177/2632352419895527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022] Open
Abstract
Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid. Gamma-aminobutyric acid action promotes sedative, anxiolytic, and anticonvulsant properties. Midazolam has a faster onset and shorter duration of action than other benzodiazepines such as diazepam and lorazepam lending itself to greater flexibility in dosing than other benzodiazepines. The kidneys excrete midazolam and its active metabolite. Metabolism occurs in the liver by the P450 system. This article examines the pharmacology, pharmacodynamics, and clinical uses of midazolam in palliative care.
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Affiliation(s)
- Eric Prommer
- UCLA/VA Hospice and Palliative Medicine Program, UCLA School of Medicine, 11301 Wilshire Blvd., Bldg. 500, Room 2064A, Los Angeles, CA 90073, USA
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17
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García Pinilla JM, Díez-Villanueva P, Bover Freire R, Formiga F, Cobo Marcos M, Bonanad C, Crespo Leiro MG, Ruiz García J, Díaz Molina B, Enjuanes Grau C, García L, Rexach L, Esteban A, Martínez-Sellés M. Documento de consenso y recomendaciones sobre cuidados paliativos en insuficiencia cardiaca de las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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18
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García Pinilla JM, Díez-Villanueva P, Bover Freire R, Formiga F, Cobo Marcos M, Bonanad C, Crespo Leiro MG, Ruiz García J, Díaz Molina B, Enjuanes Grau C, García L, Rexach L, Esteban A, Martínez-Sellés M. Consensus document and recommendations on palliative care in heart failure of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology. ACTA ACUST UNITED AC 2019; 73:69-77. [PMID: 31761573 DOI: 10.1016/j.rec.2019.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/05/2019] [Indexed: 12/21/2022]
Abstract
Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making.
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Affiliation(s)
- José Manuel García Pinilla
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Ramón Bover Freire
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Francesc Formiga
- Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Cobo Marcos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Clara Bonanad
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - María G Crespo Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Juan Ruiz García
- Servicio de Cardiología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - Beatriz Díaz Molina
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Cristina Enjuanes Grau
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Lluisa García
- Servicio de Cardiología, Hospital Universitario Dr. Josep Trueta, Girona, Spain
| | - Lourdes Rexach
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alberto Esteban
- Servicio de Cardiología, Hospital Universitario de Móstoles, Madrid, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
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19
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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20
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Won YW, Chun HS, Seo M, Kim RB, Kim JH, Kang JH. Clinical Patterns of Continuous and Intermittent Palliative Sedation in Patients With Terminal Cancer: A Descriptive, Observational Study. J Pain Symptom Manage 2019; 58:65-71. [PMID: 31026509 DOI: 10.1016/j.jpainsymman.2019.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Limited information is available regarding the detailed clinical patterns of palliative sedation (PS), that is, the symptom control rate, salvage medication, and the effectiveness of intermittent PS (IPS) versus continuous PS (CPS). OBJECTIVES The primary aim was to investigate clinical outcomes of PS in a real clinical setting. METHODS Clinical information was prospectively collected for patients who were treated according to a prescribed protocol and assessment tools in a hospice unit affiliated with a tertiary cancer center between September 2015 and March 2017. Data were analyzed retrospectively. Midazolam was used as the first medication for PS, and propofol and phenobarbital were subsequently used as salvage medications. Indications of PS, the depth of sedation, the quality of sleep, and the level of consciousness were assessed. RESULTS A total of 306 patients were enrolled, 89 of whom (29.1%) received PS. No difference in survival time was found between patients with and without PS (median survival, 34.0 vs 25.0 days, P = 0.109). Delirium was the most common indication of PS. The symptoms of 73 (82.0%) of 89 patients with PS were relieved with midazolam. Twelve (75.0%) of 16 midazolam-failure patients responded to propofol, five of whom (31%) exhibited respiratory depression. Of the 89 patients receiving PS, 61 (68.5%) received IPS and 28 patients (31.5%) received CPS. The median survival times from PS initiation to death were six days in the IPS group and one day in the CPS group (P < 0.001). Interestingly, consciousness levels were significantly improved after IPS in the delirium group compared with those in the other group (41.7% vs 16.7%, P = 0.002). CONCLUSION The refractory symptoms of end-of-life patients with cancer can ultimately be relieved with various medications for PS. IPS may improve the consciousness level of patients with delirium.
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Affiliation(s)
- Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Hye Sook Chun
- Department of Nursing, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Minjeong Seo
- College of Nursing, Gerontological Health Research Center in Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Rock Bum Kim
- Department of Preventive Medicine and Environmental Health, Institute of Health Sciences, College of Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Jung Hoon Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jung Hun Kang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea; Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Republic of Korea.
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21
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Duffy EA, Dias N, Hendricks-Ferguson V, Hellsten M, Skeens-Borland M, Thornton C, Linder LA. Perspectives on Cancer Pain Assessment and Management in Children. Semin Oncol Nurs 2019; 35:261-273. [PMID: 31078340 DOI: 10.1016/j.soncn.2019.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer. DATA SOURCES Published research and clinical guidelines. CONCLUSION Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management. IMPLICATIONS FOR NURSING PRACTICE Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.
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Affiliation(s)
| | - Nancy Dias
- East Carolina University College of Nursing, Greenville, NC
| | | | - Melody Hellsten
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Cliff Thornton
- Herman & Walter Samuelson Children's Hospital of Sinai, Division of Pediatric Hematology/Oncology, Johns Hopkins School of Nursing, Baltimore, MD
| | - Lauri A Linder
- University of Utah, College of Nursing, Salt Lake City, UT; Primary Children's Hospital, Salt Lake City, UT
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22
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Zaporowska-Stachowiak I, Szymański K, Oduah MT, Stachowiak-Szymczak K, Łuczak J, Sopata M. Midazolam: Safety of use in palliative care: A systematic critical review. Biomed Pharmacother 2019; 114:108838. [PMID: 30981104 DOI: 10.1016/j.biopha.2019.108838] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/29/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE The undesired effects of midazolam can be life-threatening. This paper delineates the findings related to the pharmacokinetics, adverse effects and drug-drug interactions as well as associated therapeutic implications for safe midazolam use. METHODS A systematic review of literature was conducted. RESULTS The pharmacokinetics of midazolam depends on hepatic and renal functions, fat tissue mass, route and duration of administration, as well as potential drug-drug interactions. Palliative care patients constitute a high-risk group prone to side effects of drugs, due to polytherapy and multi-organ failure. CONCLUSION Midazolam is one of three most frequently administered drugs in palliative care. The indications for its use include anxiety, dyspnea, seizures, vomiting refractory to treatment, agitation, myoclonus, status epilepticus, restlessness, delirium, pruritus, hiccups, insomnia, analgosedation, palliative sedation and preventing or counteracting undesired effects of ketamine.
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Affiliation(s)
- Iwona Zaporowska-Stachowiak
- Chair and Department of Pharmacology, Poznan University of Medical Sciences, Poland; Palliative Medicine In-Patient Unit, University Hospital of Lord's Transfiguration, Poznan University of Medical Sciences, Poland.
| | - Krzysztof Szymański
- Students' Scientific Society, Poznan University of Medical Sciences, Poznań, Poland
| | - Mary-Tiffany Oduah
- English Students' Research Association, Poznan University of Medical Sciences, Poland
| | - Katarzyna Stachowiak-Szymczak
- Department of Interpreting Studies and Audiovisual Translation, Institute of Applied Linguistics, University of Warsaw, Poland
| | - Jacek Łuczak
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poland
| | - Maciej Sopata
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poland
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23
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Abdul-Razzak A, Lemieux L, Snyman M, Perez G, Sinnarajah A. Description of Continuous Palliative Sedation Practices in a Large Health Region and Comparison with Clinical Practice Guidelines. J Palliat Med 2019; 22:1052-1064. [PMID: 30939060 DOI: 10.1089/jpm.2018.0372] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: Published reports of continuous palliative sedation therapy (CPST) suggest heterogeneity in practice. There is a paucity of reports that compare practice with clinical guidelines. Objectives: To assess adherence of continuous palliative sedation practices with criteria set forth in local clinical guidelines, and to describe other features including prevalence, medication dosing, duration, multidisciplinary team involvement, and concurrent therapies. Design: Retrospective chart review. Settings/Subjects: We included cases in which a midazolam infusion was ordered at the end of life. Study sites included four adult hospitals in the Calgary health region, two hospices, and a tertiary palliative care unit. Measurements: Descriptive data, including proportion of deaths involving palliative sedation therapy, number of criteria documented, midazolam dose/duration, concurrent symptom management therapies, and referrals to spiritual care, psychology, or social work. Results: CPST occurred in 602 out of 14,360 deaths (4.2%). Full adherence to criteria occurred in 7% of cases. The most commonly missed criteria were: a "C2" goals-of-care designation order (comfort care focus in the imminently dying) (84%) and documentation of imminent death in the chart (55%). Concurrent medical therapies included opioids in 98% of cases and intravenous hydration in 85% of cases. Few referrals were made to multidisciplinary care teams. Conclusions: We found low adherence to palliative sedation guidelines. This may reflect the perception that some criteria are redundant or clinically unimportant. Future work could include a study of barriers to guideline uptake, and guideline modification to provide direction on concurrent therapies and multidisciplinary team involvement.
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Affiliation(s)
- Amane Abdul-Razzak
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Laurie Lemieux
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Maggie Snyman
- Department of Family Medicine, AHS Calgary Zone, Calgary, Alberta, Canada
| | - Grace Perez
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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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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Abstract
Purpose of Review Agitation is common among older adults with dementia; its origin may be multi-factorial, and it is often difficult to treat. In this paper, we summarize current knowledge and offer considerations on pharmacologic management of behavioral and psychological symptoms of dementia (BPSD). Recent Findings We reviewed human studies published from 2013 to 2018 evaluating pharmacologic management of BPSD manifestations including depressive symptoms, mania, psychosis, and other BPSD, as well as severe agitation without determination of underlying cause. After non-pharmacological management is exhausted, the choice of pharmacological options depends on patient comorbidities, specific BPSD presentation, and patient tolerance of medications. Summary Depending on manifestations of BPSD, low- to moderate-quality evidence supports the use of anti-depressants, anti-psychotics, or anti-epileptics in conjunction with cholinesterase inhibitors. The current evidence base needs to be augmented with future research that focuses on real-world medication use alongside head-to-head evaluation of medication effectiveness rather than comparison to placebo.
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Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication. Curr Opin Support Palliat Care 2018; 12:489-494. [PMID: 30239384 PMCID: PMC6261485 DOI: 10.1097/spc.0000000000000395] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW To provide an evidence-based synopsis on the role of benzodiazepines in patients with agitated delirium. RECENT FINDINGS Existing evidence supports the use of benzodiazepines in two specific delirium settings: persistent agitation in patients with terminal delirium and delirium tremens. In the setting of terminal delirium, the goal of care is to maximize comfort, recognizing that patients are unlikely to recover from their delirium. A recent randomized trial suggests that lorazepam in combination with haloperidol as rescue medication was more effective than haloperidol alone for the management of persistent restlessness/agitation in patients with terminal delirium. In patients with refractory agitation, benzodiazepines may be administered as scheduled doses or continuous infusion for palliative sedation. Benzodiazepines also have an established role in management of delirium secondary to alcohol withdrawal. Outside of these two care settings, the role of benzodiazepine remains investigational and clinicians should exercise great caution because of the risks of precipitating or worsening delirium and over-sedation. SUMMARY Benzodiazepines are powerful medications associated with considerable risks and benefits. Clinicians may prescribe benzodiazepines skillfully by selecting the right medication at the right dose for the right indication to the right patient at the right time.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, USA
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27
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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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Bodnar J. Terminal Withdrawal of Mechanical Ventilation: A Hospice Perspective for the Intensivist. J Intensive Care Med 2018; 34:156-164. [PMID: 30189788 DOI: 10.1177/0885066618797918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The intensive care unit (ICU) and hospice inpatient unit (IPU) environments differ in many ways. Although both endeavor to provide the best care possible for their patients, the day-to-day goals of these environments are almost antithetical. Similarly, the experiences and expertise of the staff differ. When performing a similar clinical task, it may be addressed in different ways because each group is engrained in their primary day-to-day focus. Terminal withdrawal of mechanical ventilation is a procedure that is performed in both ICUs and some hospice IPUs. Previous examinations of this subject have been based largely upon the correlative background, practices, and perceptions of the ICU prescriber. The purpose of this review is to examine how the manner in which this procedure is performed in the hospice environment may differ in ways that the intensivist can incorporate into their own plan of care, or better appreciate when making the decision to remove mechanical ventilation in the critical care unit or transfer the patient to a hospice environment for the procedure to be completed.
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Affiliation(s)
- John Bodnar
- 1 Neighborhood Hospice, Penn Medicine Chester County Hospital, West Chester, PA, USA
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Yu B, Gao W, Zhou H, Miao X, Chang Y, Wang L, Xu M, Ni G. Propofol induces apoptosis of breast cancer cells by downregulation of miR-24 signal pathway. Cancer Biomark 2018; 21:513-519. [PMID: 29103019 DOI: 10.3233/cbm-170234] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Propofol, an intravenous anesthetic agent, has been found to inhibit growth of breast cancer cells. However, the mechanisms underlying the antitumor are not known. A recent report has found that propofol could significantly downregulate miR-24 expression in the human malignant cancers. In breast cancer cells, overexpression of miR-24 promotes cell proliferation and inhibits cell apoptosis by downregulation of p27. The miR-24 has been reported to be overexpressed in breast cancer and breast cancer cell lines. In the present study, we hypothesized that propofol induces apoptosis of breast cancer cells by miR-24/p27 signal pathway. METHODS Breast cancer MDA-MB-435 cells were exposed to propofol (10 μM) for 6 hr and cell death was assessed using TUNEL staining, Flow cytometry and cleaved caspase-3 expression. microRNA-24 (miR-24) expression was assessed using quantitative reverse transcription polymerase chain reaction (qRT-PCR). miR-24 was overexpressed using a miR-24 mimic. P27 was knocked down using a small interfering RNA. p27 and cleaved caspase-3 expression was assessed by Western blot. RESULTS MDA-MB-435 exposed to propofol showed a significant increase in apoptotic cells, followed by the downregulation of miR-24, upregulation of p27 expression and cleaved caspase-3 expression. Targeting p27 inhibits propofol-induced cell apoptosis; miR-24 overexpression decreased propofol-induced cell apoptosis, cleaved caspase-3 and p27 expression. CONCLUSIONS Propofol inducescell death in MDA-MB-435 cells via inactivation of miR-24/p27 signal pathway.
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Affiliation(s)
- Benxia Yu
- Department of Imaging, Yantai Yuhuangding Hospital, Yantai, Shandong, China.,Department of Imaging, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Wei Gao
- Department of Imaging, Yantai Yuhuangding Hospital, Yantai, Shandong, China.,Department of Imaging, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Hui Zhou
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Xia Miao
- Department of Clinical Laboratory, The Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Yuan Chang
- Department of Anesthesiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Liping Wang
- Department of Imaging, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Miao Xu
- Department of Clinical Laboratory, The Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Guangzhen Ni
- Department of Clinical Laboratory, The Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
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30
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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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