A Survey of Hospice and Palliative Care Clinicians' Experiences and Attitudes Regarding the Use of Palliative Sedation

The Attitudes and Experiences of Hospice Nurses Regarding Palliative Sedation: A Cross-Sectional Descriptive Study

Background: Despite the global acceptance of palliative sedation, China's engagement in this field remains comparatively restricted. There exists a scarcity of information regarding the attitudes and experiences of hospice nurses concerning palliative sedation. Objectives: This survey aimed at investigating the attitudes of Chinese hospice nurses toward palliative sedation, as well as their practices in palliative sedation. Design: A cross-sectional descriptive study. Setting/Subjects: In 2023, the survey on palliative sedation was introduced during the opening ceremony of the largest National Symposium on New Advances in Hospice Nursing in China. Subsequently, the study questionnaire was disseminated through email to a cohort of 806 hospice nurses attending the conference. Measurements/Results: The statistical analysis was based on 641 valid responses. Among them, 508 had no experience with palliative sedation, while only 133 had such experience. Around 92.5% of hospice nurses with experience in palliative sedation agreed with the physician's instructions to begin palliative sedation. Nurses were present at the start of sedation in nearly all cases (97.0%), and most doctors (79.7%) and family members (82.0%) were also present. However, 8.3% of them perceived that there was no difference between palliative sedation and euthanasia. Furthermore, 13.5% of participants believed that the purpose of palliative sedation was to hasten death. Conclusions: Hospice nurses play a crucial role in the process of palliative sedation, yet they also face significant challenges. It suggests that there is an urgent need in China for the development of consensus or guidelines for palliative sedation to clarify the roles of team members, including hospice nurses.

Palliative sedation determinants: systematic review and meta-analysis in palliative medicine

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.

Complexes of N- and O-Donor Ligands as Potential Urease Inhibitors

We report five new transition-metal complexes that inhibit the urease enzyme. Barbituric acid (BTA), thiobarbituric acid (TBA), isoniazid (INZ), and nicotinamide (NCA) ligands were employed in complexation reactions. The resulting complexes were characterized using a variety of analytical techniques including infra-red and UV-vis spectroscopy, ¹H NMR spectroscopy, elemental analysis, and single-crystal X-ray diffraction analysis. We describe two mononuclear complexes with a general formula {[M(NCA)₂(H₂O)₄](BTA)₂(H₂O)}, where M = Co (1) and Zn (2), a mononuclear complex {[Ni(NCA)₂(H₂O)₄](TBA)₂(H₂O)} (3), and two polymeric chains of a general formula {[M(INZ) (H₂O)₃](BTA)₂(H₂O)₃}, where M = Co (4) and Zn (5). These complexes displayed significant urease enzyme inhibition with IC₅₀ values in the range of 3.9-19.9 μM.

Physicians' perceptions of palliative sedation for existential suffering: a systematic review

BACKGROUND

Palliative sedation for existential suffering (PS-ES) is a controversial clinical intervention. Empirical studies about physicians' perceptions do not converge in a clear position and current clinical practice guidelines do not agree either regarding this kind of intervention.

AIM

To gain deeper insight into physicians' perceptions of PS-ES, the factors influencing it, the conditions for implementing it and the alternatives to it.

DESIGN

Systematic review of qualitative, quantitative and mixed-methods studies following the Peer Review Electronic Search Strategies and Preferred Reporting Items for Systematic Reviews and Meta-analyses protocols; quality appraisal and thematic synthesis methodology.

DATA SOURCES

Seven electronic databases (PubMed, CINAHL, Embase, Scopus, Web of Science, PsycINFO, PsycARTICLES) were exhaustively searched from inception through March 2019. Two reviewers screened paper titles, abstracts and full texts. We included only peer-reviewed journal articles published in English, French, German, Dutch, Spanish, Italian or Portuguese that focused on physicians' perceptions of PS-ES.

RESULTS

The search yielded 17 publications published between 2002 and 2017. Physicians do not hold clear views or agree if and when PS-ES is appropriate. Case-related and individual-related factors that influenced physicians' perceptions were identified. There is still no consensus regarding criteria to distinguish between necessary and sufficient conditions for invoking PS-ES. Some alternatives to PS-ES were identified.

CONCLUSIONS

To date, there is still no consensus on physicians' perceptions of PS-ES. Further research is necessary to understand factors that influence physicians' perceptions and philosophical-ethical presuppositions underlying this perceptions.

Palliative Sedation for the Terminally Ill Patient

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.

'Palliative sedation'? A retrospective cohort study on the use and labelling of continuously administered sedatives on a palliative care unit

BACKGROUND

Sedatives are frequently used towards the end of life. However, there is scarce information when their use is labelled as 'palliative sedation'.

AIM

To assess the use and labelling of 'continuous administration of sedatives within the last 7 days of life', based on objective operational criteria, on a palliative care unit.

DESIGN

Retrospective cohort study, using medical records. Explorative statistical analysis (SPSS 23).

SETTING/PARTICIPANTS

Patients who died on a palliative care unit from August 2014 to July 2015. Sedatives recorded were benzodiazepines, levomepromazine, haloperidol ⩾5 mg/day and propofol.

RESULTS

Of the 192 patients, 149 (78%) patients received continuous sedatives within the last week of life. The prevalence of delirium/agitation was significantly higher in patients with continuous sedatives compared to those without continuous sedatives at admission to the unit (35% vs 16%, p = 0.02) and on the day before death (58% vs 40%, p = 0.04). The term '(palliative) sedation' was used in the records for 22 of 149 (15%) patients with continuous sedatives. These patients had significantly higher total daily midazolam doses 2 days before death (median (range), 15.0 (6.0-185.0) mg vs 11.5 (1.0-70.0) mg, p = 0.04) and on the day of death (median (range), 19.5 (7.5-240.0) mg vs 12.5 (2.0-65.0) mg, p = 0.01). The dose range was large in both groups.

CONCLUSION

The prevalence of delirium/agitation was associated with the administration of continuous sedatives. There was no consistent pattern regarding labelling the use of continuous sedatives as '(palliative) sedation'. Multicentre mixed-methods research is needed for a better characterization of sedation practices in palliative care.

How are we managing fistulating perianal Crohn's disease? Results of a national survey of consultant gastroenterologists

OBJECTIVE

Fistulating perianal Crohn's disease represents a significant challenge to both clinicians and patients. This survey set out to describe current practice and variation in the medical management of this condition.

DESIGN

A survey was designed by an expert group of gastroenterologists and surgeons with an inflammatory bowel disease (IBD) interest. The questionnaire aimed to capture opinions from consultant gastroenterologists with a UK practice on the management of acutely symptomatic fistula, assessment of a new fistula presentation, medical management strategies and surgical intervention. The survey was piloted at the British Society of Gastroenterology Clinical Research Group meeting, and distributed at UK gastroenterology meetings.

RESULTS

There were 111 completed responses (response rate 55%). Following clearance of sepsis, 22.1% of respondents would wait 6 weeks or more before commencing medical therapy. Antibiotics were used by 89.2%, with a variable duration. First-line medical therapy was thiopurine for 48% and antitumour necrosis factor (TNF) for 50% of respondents. These were used in combination by 44.4%. Interval to escalation of therapy (if required) varied from 1 month to a year. Anti-TNF therapies were favoured in deteriorating patients. An IBD multidisciplinary team was accessible to 98%, although only 23.6% routinely discussed these patients. Optimisation strategies for anti-TNF and thiopurines were used by 70% of respondents. Recurrent sepsis, refractory disease and patient choice are indications for surgical referral.

CONCLUSION

These results illustrate the huge variation in practice and lack of consensus among physicians for the optimal medical management of perianal Crohn's disease. There are gaps in knowledge that require targeted research.