1
|
Pozsgai É, Garralda E, Busa C, Payne S, Hasselaar J, Mosoiu D, Surges SM, Van der Elst M, Mercadante S, Centeno C, Csikós Á. Report on palliative sedation medication usage: a survey of palliative care experts in Eight European countries. BMC Palliat Care 2024; 23:154. [PMID: 38902670 PMCID: PMC11188245 DOI: 10.1186/s12904-024-01484-6] [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: 04/18/2023] [Accepted: 06/06/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND The practice of palliative sedation continues to raise ethical questions among people, which in turn leads to its varied acceptance and practice across regions. As part of the Palliative Sedation European Union (EU) project, the aim of the present study was to determine the perceptions of palliative care experts regarding the practice of palliative sedation in eight European countries (The Netherlands, Belgium, Germany, UK, Italy, Spain, Hungary, and Romania). METHODS A specifically designed survey, including questions on the most frequently used medications for palliative sedation, their availability per countries and settings, and the barriers and facilitators to the appropriate practice of palliative sedation was sent to expert clinicians involved and knowledgeable in palliative care in the indicated countries. A purposive sampling strategy was used to select at least 18 participating clinicians per consortium country. Descriptive statistical analysis was conducted on the survey data. RESULTS Of the 208 expert clinicians invited to participate, 124 participants completed the survey. Midazolam was perceived to be the most frequently used benzodiazepine in all eight countries. 86% and 89% of expert clinicians in Germany and Italy, respectively, perceived midazolam was used "almost always", while in Hungary and Romania only about 50% or less of the respondents perceived this. Levomepromazine was the neuroleptic most frequently perceived to be used for palliative sedation in the Netherlands, Spain, Germany, and the United Kingdom. Between 38- 86% of all eight countries´ expert clinicians believed that opioid medications were "almost always" used during palliative sedation. The perceived use of IV hydration and artificial nutrition "almost always" was generally low, while the country where both IV hydration and artificial nutrition were considered to be "very often" given by a third of the expert clinicians, was in Hungary, with 36% and 27%, respectively. CONCLUSIONS Our study provides insight about the differences in the perceived practice of medication during palliative sedation between eight European countries. In countries where palliative care services have been established longer perceptions regarding medication use during palliative sedation were more in line with the recommended European guidelines than in Central and Eastern European countries like Romania and Hungary.
Collapse
Affiliation(s)
- Éva Pozsgai
- Department of Primary Health Care, University of Pecs Medical School, Pécs, Hungary.
- Department of Public Health Medicine, University of Pécs Medical School, Pecs, Hungary.
| | - Eduardo Garralda
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Csilla Busa
- Institute of Primary Health Care, University of Pécs Medical School, Pécs, Hungary
| | - Sheila Payne
- International Observatory On End of Life Care, Lancaster University, Lancaster, UK
| | - Jeroen Hasselaar
- Department of Primary Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniela Mosoiu
- Transylvania University Brasov, Hospice Casa Sperantei, Brasov, Romania
| | - Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Michaël Van der Elst
- Department of Oncology, Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sebastiano Mercadante
- Main Regional Center for Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | - Carlos Centeno
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Ágnes Csikós
- Institute of Primary Health Care, University of Pécs Medical School, Pécs, Hungary
| |
Collapse
|
2
|
Surges SM, Brunsch H, Jaspers B, Apostolidis K, Cardone A, Centeno C, Cherny N, Csikós À, Fainsinger R, Garralda E, Ling J, Menten J, Mercadante S, Mosoiu D, Payne S, Preston N, Van den Block L, Hasselaar J, Radbruch L. Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study. Palliat Med 2024; 38:213-228. [PMID: 38297460 PMCID: PMC10865771 DOI: 10.1177/02692163231220225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability. AIM To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers. DESIGN Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure. SETTING European. PARTICIPANTS International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation. RESULTS A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided. CONCLUSIONS This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.
Collapse
Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | | | - Antonella Cardone
- Cancer Patients Europe, Brussels, Belgium
- Pancreatic Cancer Europe, Brussels, Belgium
| | - Carlos Centeno
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Nathan Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Àgnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | | | - Eduardo Garralda
- ATLANTES Global Observatory of Palliative Care, Institute for Culture and Society, University of Navarra, Pamplona, Spain
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Julie Ling
- European Association for Palliative Care, Vilvoorde, Belgium
| | - Johan Menten
- Laboratory of Experimental Radiotherapy, KU Leuven, Leuven, Belgium
| | - Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative/Supportive Care, La Maddalena Cancer Centre, Palermo, Italy
| | - Daniela Mosoiu
- Medical Faculty, Transilvania University, Brasov, Romania
- Education and National Development Department, Hospice Casa Sperantei, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jeroen Hasselaar
- Department of Primary Care, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Task Force on Palliative Sedation of the European Association for Palliative Care, Brussels, Belgium
| |
Collapse
|
3
|
Kauzner S, Heckel M, Ostgathe C, Schneider M, Bausewein C, Schildmann E, Kremling A, Ziegler K, Klein C. Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates. J Palliat Med 2023; 26:1277-1284. [PMID: 37155703 DOI: 10.1089/jpm.2022.0476] [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: 05/10/2023] Open
Abstract
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.
Collapse
Affiliation(s)
- Saskia Kauzner
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuela Schneider
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care and Charité Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| |
Collapse
|
4
|
Surges SM, Garralda E, Jaspers B, Brunsch H, Rijpstra M, Hasselaar J, Van der Elst M, Menten J, Csikós Á, Mercadante S, Mosoiu D, Payne S, Centeno C, Radbruch L. Review of European Guidelines on Palliative Sedation: A Foundation for the Updating of the European Association for Palliative Care Framework. J Palliat Med 2022; 25:1721-1731. [PMID: 35849746 DOI: 10.1089/jpm.2021.0646] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making process. Several weaknesses were highlighted, particularly in areas of rigor of development and applicability. The identified points of debate and methodological weaknesses should be considered in any update or revision of the guidelines analyzed to improve the quality of their content and the applicability of their recommendations.
Collapse
Affiliation(s)
- Séverine M Surges
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Eduardo Garralda
- ATLANTES Global Palliative Care Observatory, Institute for Culture and Society, University of Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Birgit Jaspers
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany.,Department of Palliative Medicine, University Medicine Goettingen, Goettingen, Germany
| | - Holger Brunsch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre (Radboudumc), Nijmegen, the Netherlands
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre (Radboudumc), Nijmegen, the Netherlands
| | | | - Johan Menten
- Laboratory of Experimental Radiotherapy, UH & KU Leuven, Leuven, Belgium
| | - Ágnes Csikós
- Department of Primary Health Care, Department of Hospice-Palliative Care, University of Pecs Medical School, Pecs, Hungary
| | - Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative/Supportive Care, La Maddalena Cancer Centre, Palermo, Italy
| | - Daniela Mosoiu
- Medical Faculty, Transilvania University, Brasov, Brasov, Romania.,Education and National Development Department, Hospice Casa Sperantei, Brasov, Brasov, Romania
| | - Sheila Payne
- International Observatory on End-of-Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Carlos Centeno
- ATLANTES Global Palliative Care Observatory, Institute for Culture and Society, University of Navarra, Pamplona, Spain.,IdiSNA, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
5
|
Arantzamendi M, Belar A, Payne S, Rijpstra M, Preston N, Menten J, Van der Elst M, Radbruch L, Hasselaar J, Centeno C. Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review. J Pain Symptom Manage 2021; 61:831-844.e10. [PMID: 32961218 DOI: 10.1016/j.jpainsymman.2020.09.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/25/2022]
Abstract
CONTEXT Near the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed. OBJECTIVES To explore clinical aspects of palliative sedation in recent prospective studies. METHODS Systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019), combining sedation, palliative care, and prospective. Article quality was assessed. RESULTS Ten prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%-83%), pain (25%-65%), and dyspnea (16%-59%). In some articles, psychological and existential distress were mentioned (16%-59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication-propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort. CONCLUSION Assessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.
Collapse
Affiliation(s)
- Maria Arantzamendi
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain
| | - Alazne Belar
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain.
| | - Sheila Payne
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Maaike Rijpstra
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Johan Menten
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Van der Elst
- Department of Oncology, Laboratory of experimental radiotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lukas Radbruch
- Department of Palliative Medicine, Universitaetsklinikum Bonn, Bonn, Germany
| | - Jeroen Hasselaar
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Carlos Centeno
- Instituto Cultura y Sociedad, ATLANTES, Universidad de Navarra, Pamplona, Spain; IdISNA, Pamplona, Spain; Clínica Universidad de Navarra, Departamento Medicina Paliativa, Pamplona, Spain
| |
Collapse
|