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

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

BACKGROUND

The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation.

AIM

This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation.

DESIGN

We conducted a qualitative study based on focus group discussions.

SETTING/PARTICIPANTS

We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized.

RESULTS

An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death.

CONCLUSIONS

Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.

Palliative sedation - revised recommendations

Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.

Sédation profonde et continue jusqu’au décès : qu’en vivent les soignants ?

Objectif : La récente loi Claeys-Leonetti de 2016 reconnaît le droit du patient à une sédation profonde et continue jusqu’au décès (SPCJD) si ce dernier en fait la demande. Au quotidien, comment les équipes soignantes s’approprient cette nouvelle possibilité et s’adaptent à ces situations de fin de vie spécifiques ?

Méthode : Nous avons mené des entretiens semi-directifs avec six soignants volontaires de chaque corps de métier (deux médecins, deux infirmier.ère.s et deux aides-soignantes) dans un service d’oncologie médicale et de radiothérapie. Les entretiens ont été analysés selon une méthode d’analyse de contenu thématique, afin de rendre compte du vécu des professionnels de soins face aux protocoles de SPCJD et aux conséquences sur les accompagnements de fin de vie dans ces circonstances.

Résultats : Cette enquête exploratoire met en évidence des disparités interprofessionnelles quant au vécu des accompagnements de patients sous SPCJD. L’hétérogénéité des représentations semble liée à une méconnaissance de la loi, à des acceptions variables, mais aussi à des intentions différentes en fonction des fonctions exercées. La continuité dans la prise en charge des patients est affectée : le seul point commun observé chez tous les professionnels concerne les difficultés décrites dans l’accompagnement des familles.

Conclusion : La loi Claeys-Leonetti, ayant pour objectif de donner davantage de droits aux patients, pose des enjeux éthiques et des difficultés aux soignants encore trop peu investigués à ce jour. Il semble fondamental de tenir compte de l’effet de cette procédure sur le vécu des professionnels, afin que la mise en place des protocoles soit accompagnée et pensée au mieux, dans le but de limiter les potentielles difficultés et souffrances relatives à la SPCJD.