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
|
Heijltjes MT, Morita T, Mori M, Heckel M, Klein C, Stiel S, Miccinesi G, Deliens L, Robijn L, Stone P, Sykes N, Hui D, Krishna L, van Delden JJM, van der Heide A, Rietjens JAC. Physicians' Opinion and Practice With the Continuous Use of Sedatives in the Last Days of Life. J Pain Symptom Manage 2022; 63:78-87. [PMID: 34333097 DOI: 10.1016/j.jpainsymman.2021.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT There are few international studies about the continuous use of sedatives (CUS) in the last days of life. OBJECTIVES We aim to describe the experiences and opinions regarding CUS of physicians caring for terminally ill patients in seven countries. METHODS Questionnaire study about practices and experiences with CUS in the last days of life among physicians caring for terminally ill patients in Belgium (n = 175), Germany (n = 546), Italy (n = 214), Japan (n = 513), the Netherlands (n = 829), United Kingdom (n = 114) and Singapore (n = 21). RESULTS The overall response rate was 22%. Of the respondents, 88-99% reported that they had clinical experience of CUS in the last 12 months. More than 90% of respondents indicated that they mostly used midazolam for sedation. The use of sedatives to relieve suffering in the last days of life was considered acceptable in cases of physical suffering (87%-99%). This percentage was lower but still substantial in cases of psycho-existential suffering in the absence of physical symptoms (45%-88%). These percentages were lower when the prognosis was at least several weeks (22%-66% for physical suffering and 5%-42% for psycho-existential suffering). Of the respondents, 10% or less agreed with the statement that CUS is unnecessary because suffering can be alleviated with other measures. A substantial proportion (41%-95%) agreed with the statement that a competent patient with severe suffering has the right to demand the use of sedatives in the last days of life. CONCLUSION Many respondents in our study considered CUS acceptable for the relief of physical and psycho-existential suffering in the last days of life. The acceptability was lower regarding CUS for psycho-existential suffering and regarding CUS for patients with a longer life expectancy.
Collapse
Affiliation(s)
- Madelon T Heijltjes
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands.
| | - Tatsuya Morita
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division (T.M., M.M.), Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Maria Heckel
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine (M.H., C.K.), CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephanie Stiel
- Hannover Medical School (S.S.), Institute for General Practice and Palliative Care, Düsseldorf, Germany
| | - Guido Miccinesi
- Oncological network (G.M.), Prevention and Research Institute-ISPRO, Firenze, Italy
| | - Luc Deliens
- Vrije Universiteit Brussel (L.D.), Ixelles, Belgium
| | - Lenzo Robijn
- Department of Public Health and Primary Care (L.R.), Ghent University, Ghent, Belgium
| | - Patrick Stone
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - Nigel Sykes
- Marie Curie Palliative Care Research Department (P.S., N.S.), University College London, London, United Kingdom
| | - David Hui
- MD Anderson Cancer Center (D.H.), University of Texas, Texas, USA
| | | | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care (M.T.H., J.J.M.V.D.), UMC Utrecht, Utrecht, The Netherlands
| | - Agnes van der Heide
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Erasmus MC (A.V.D.H., J.A.C.R.), University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Booker R, Bruce A. Palliative sedation and medical assistance in dying: Distinctly different or simply semantics? Nurs Inq 2019; 27:e12321. [PMID: 31756038 PMCID: PMC9285680 DOI: 10.1111/nin.12321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/17/2019] [Accepted: 08/03/2019] [Indexed: 11/29/2022]
Abstract
Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for clinicians and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada.
Collapse
Affiliation(s)
- Reanne Booker
- Palliative and End-of-Life Care Services, Calgary, AB, Canada.,Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Anne Bruce
- School of Nursing, University of Victoria, Victoria, BC, Canada
| |
Collapse
|
4
|
The role of end-of-life palliative sedation: medical and ethical aspects – Review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 29776669 PMCID: PMC9391748 DOI: 10.1016/j.bjane.2018.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background and objective Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined. Method An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications. Conclusions Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients’ monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.
Collapse
|
5
|
Menezes MS, Figueiredo MDGMDCDA. [The role of end-of-life palliative sedation: medical and ethical aspects - Review]. Rev Bras Anestesiol 2018; 69:72-77. [PMID: 29776669 DOI: 10.1016/j.bjan.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 02/28/2018] [Accepted: 03/31/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined. METHOD An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications. CONCLUSIONS Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients' monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.
Collapse
Affiliation(s)
- Miriam S Menezes
- Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brasil.
| | | |
Collapse
|
6
|
Lokker ME, Swart SJ, Rietjens JAC, van Zuylen L, Perez RSGM, van der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res 2018; 40:157-161. [PMID: 29579492 DOI: 10.1016/j.apnr.2018.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/06/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.
Collapse
Affiliation(s)
- M E Lokker
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands; Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands.
| | - S J Swart
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - J A C Rietjens
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - L van Zuylen
- Department of Medical Oncology, Erasmus MC, Rotterdam, The Netherlands
| | - R S G M Perez
- Department of Anesthesiology, VUmc, Amsterdam, The Netherlands
| | - A van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Abarshi E, Rietjens J, Robijn L, Caraceni A, Payne S, Deliens L, Van den Block L. International variations in clinical practice guidelines for palliative sedation: a systematic review. BMJ Support Palliat Care 2017; 7:223-229. [PMID: 28432090 DOI: 10.1136/bmjspcare-2016-001159] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 01/09/2017] [Accepted: 04/01/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Palliative sedation is a highly debated medical practice, particularly regarding its proper use in end-of-life care. Worldwide, guidelines are used to standardise care and regulate this practice. In this review, we identify and compare national/regional clinical practice guidelines on palliative sedation against the European Association for Palliative Care (EAPC) palliative sedation Framework and assess the developmental quality of these guidelines using the Appraisal Guideline Research and Evaluation (AGREE II) instrument. METHODS Using the PRISMA criteria, we searched multiple databases (PubMed, CancerLit, CINAHL, Cochrane Library, NHS Evidence and Google Scholar) for relevant guidelines, and selected those written in English, Dutch and Italian; published between January 2000 and March 2016. RESULTS Of 264 hits, 13 guidelines-Belgium, Canada (3), Ireland, Italy, Japan, the Netherlands, Norway, Spain, Europe, and USA (2) were selected. 8 contained at least 9/10 recommendations published in the EAPC Framework; 9 recommended 'pre-emptive discussion of the potential role of sedation in end-of-life care'; 9 recommended 'nutrition/hydration while performing sedation' and 8 acknowledged the need to 'care for the medical team'. There were striking differences in terminologies used and in life expectancy preceding the practice. Selected guidelines were conceptually similar, comparing closely to the EAPC Framework recommendations, albeit with notable variations. CONCLUSIONS Based on AGREE II, 3 guidelines achieved top scores and could therefore be recommended for use in this context. Also, domains 'scope and purpose' and 'editorial independence' ranked highest and lowest, respectively-underscoring the importance of good reportage at the developmental stage.
Collapse
Affiliation(s)
- Ebun Abarshi
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Judith Rietjens
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands.,End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lenzo Robijn
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Augusto Caraceni
- Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy.,European Palliative Care Research Center, Norwegian University of Science and Technology Trondheim Norway, EAPC Research Network
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster, United Kingdom
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | |
Collapse
|
8
|
van Deijck RHPD, Hasselaar JGJ, Verhagen SCAHHVM, Vissers KCP, Koopmans RTCM. Level of Discomfort Decreases After the Administration of Continuous Palliative Sedation: A Prospective Multicenter Study in Hospices and Palliative Care Units. J Pain Symptom Manage 2016; 52:361-9. [PMID: 27387345 DOI: 10.1016/j.jpainsymman.2016.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/10/2016] [Accepted: 05/20/2016] [Indexed: 12/13/2022]
Abstract
CONTEXT A gold standard or validated tool for monitoring the level of discomfort during continuous palliative sedation (CPS) is lacking. Therefore, little is known about the course of discomfort in sedated patients, the efficacy of CPS, and the determinants of discomfort during CPS. OBJECTIVES To identify the course of discomfort in patients receiving CPS. METHODS A prospective observational multicenter study in nine hospices and palliative care units was performed. The Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) was independently assessed for monitoring of patient discomfort during CPS. The DS-DAT scores range from 0 (no observed discomfort) to a maximum of 27 (high level of observed discomfort). Using a mixed model, the mean group score of discomfort between four predefined time frames of CPS was compared, correcting for confounding patient characteristics. RESULTS A total of 130 patients were sedated, and the DS-DAT was completed in 106 patients at least once. The median duration of the sedation in these 106 patients was 25.5 hours (range 2-161). The mean score of the DS-DAT in the phase before sedation was 12.16 (95% CI 9.83-14.50) and decreased significantly to 8.06 (95% CI 5.53-10.58) in the titration phase of sedation. The mean score of the DS-DAT in the final phase of sedation was 7.42 (95% CI 4.90-9.94). CONCLUSION This study shows that CPS is associated with a decrease in the level of discomfort within an acceptable time frame, although in some sedated patients higher levels of discomfort in the last hours of life occurred. Although the DS-DAT seems to be of value for monitoring the level of discomfort during CPS, the results of this study should be interpreted within the constraints of the limitations, and further research on the psychometric properties of this tool is needed before the DS-DAT can be used in clinical practice.
Collapse
Affiliation(s)
| | - Jeroen G J Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stans C A H H V M Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; De Waalboog, "Joachim en Anna" Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
| |
Collapse
|
9
|
Affiliation(s)
- Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy
| | | |
Collapse
|
10
|
Swart SJ, van der Heide A, van Zuylen L, Perez RSGM, Zuurmond WWA, van der Maas PJ, van Delden JJM, Rietjens JAC. Continuous palliative sedation: not only a response to physical suffering. J Palliat Med 2014; 17:27-36. [PMID: 24410419 DOI: 10.1089/jpm.2013.0121] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Palliative sedation is a medical intervention aimed at relieving symptoms that can no longer be controlled by conventional treatment. Ample knowledge is available regarding the nature of such symptoms, but there is no in-depth information regarding how health care workers decide about palliative sedation. OBJECTIVE The study objective was to investigate considerations concerning the indications for continuous palliative sedation (CPS) and issues that influence these considerations. DESIGN The study consisted of qualitative interviews regarding patients who had recently received CPS. SETTING/SUBJECTS The study involved physicians and nurses working in general practice, nursing homes, and hospitals. MEASUREMENT Analyses by a multidisciplinary research team used the constant comparative method. RESULTS Together with physical symptoms, psychological and existential suffering may combine to produce a refractory state for which other treatment options than CPS were not available or considered inappropriate. A limited life expectancy was by many considered crucial (e.g., to avoid hastening death) and by some less important (e.g., because the patient's suffering was considered to be key). Issues influencing the decision to use CPS related to patient preferences (e.g., dignity, not wanting to experience further suffering) or family issues (impact of suffering on family, family requesting CPS). CONCLUSIONS The indication for CPS typically originates from physical symptoms and nonphysical problems producing a refractory state in which a patient suffers unbearably. In such states, preferences of patients and families and the life expectancy criterion are weighed against the severity of refractory symptoms. Therefore the use of CPS is not only a response to the physical suffering of patients in the dying phase.
Collapse
Affiliation(s)
- Siebe J Swart
- 1 Department of Public Health, Erasmus Medical Centre , Rotterdam, the Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Bush SH, Leonard MM, Agar M, Spiller JA, Hosie A, Wright DK, Meagher DJ, Currow DC, Bruera E, Lawlor PG. End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase. J Pain Symptom Manage 2014; 48:215-30. [PMID: 24879997 DOI: 10.1016/j.jpainsymman.2014.05.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 01/21/2023]
Abstract
CONTEXT In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase. OBJECTIVES To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review. RESULTS The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan. CONCLUSION Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.
Collapse
Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Maeve M Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Meera Agar
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Juliet A Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, United Kingdom
| | - Annmarie Hosie
- Faculty of Nursing, University of Notre Dame, Sydney, New South Wales, Australia
| | | | - David J Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - David C Currow
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Eduardo Bruera
- The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
12
|
Sercu M, Pype P, Christiaens T, Derese A, Deveugele M. Belgian general practitioners' perspectives on the use of palliative sedation in end-of-life home care: a qualitative study. J Pain Symptom Manage 2014; 47:1054-63. [PMID: 24095283 DOI: 10.1016/j.jpainsymman.2013.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 06/17/2013] [Accepted: 07/07/2013] [Indexed: 11/21/2022]
Abstract
CONTEXT Palliative sedation (PS) is a far-reaching palliative measure with a life-shortening potential. Guidelines provide only for a restricted use of PS and as a last resort. OBJECTIVES To explore PS practice in end-of-life (EoL) home care. METHODS This was a qualitative analysis of semi-structured interviews with 52 general practitioners (GPs) of Flanders, Belgium. RESULTS Apart from GPs who adhere to the existing prerequisites for PS, opinions diverge among GPs on the indication area for PS and on possible life-shortening intentions. The key to GPs' broadened view on "which suffering merits PS" is the fragile context of EoL home care, and the key to GPs' possible life-shortening intentions is their need to facilitate the dying process, when trying or lengthy. When honoring a terminally ill patient's request for euthanasia, several GPs prefer slow euthanasia using PS to a lethal injection. CONCLUSION PS home practice deviates from the PS guidelines' recommendations. In addition to the GPs' shortage of knowledge, the guidelines' recommendations do not always meet the particular needs of EoL home care. If one consideration of EoL home care is to respect a patient's wish to die at home, then the pre-emptive use of PS to avoid a futile transfer to the hospital in the case of an undesirable turn of events deserves more attention in the PS debate.
Collapse
Affiliation(s)
- Maria Sercu
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium.
| | - Peter Pype
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Thierry Christiaens
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Anselme Derese
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Myriam Deveugele
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| |
Collapse
|
13
|
McKinnon M, Azevedo C, Bush SH, Lawlor P, Pereira J. Practice and documentation of palliative sedation: a quality improvement initiative. ACTA ACUST UNITED AC 2014; 21:100-3. [PMID: 24764700 DOI: 10.3747/co.21.1773] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Palliative sedation (ps), the continuous use of sedating doses of medication to intentionally reduce consciousness and relieve refractory symptoms at end of life, is ethically acceptable if administered according to standards of best practice. Procedural guidelines outlining the appropriate use of ps and the need for rigorous documentation have been developed. As a quality improvement strategy, we audited the practice and documentation of ps on our palliative care unit (pcu). METHODS A pharmacy database search of admissions in 2008 identified, for a subsequent chart review, patients who had received either a continuous infusion of midazolam (≥10 mg/24 h), regular parenteral dosing of methotrimeprazine (≥75 mg daily), or regular phenobarbital. Documentation of the decision-making process, consent, and medication use was collected using a data extraction form based on current international ps standards. RESULTS Interpretation and comparison of data were difficult because of an apparent lack of a consistent operational definition of ps. Patient records had no specific documentation in relation to ps initiation, to clearly identified refractory symptoms, and to informed consent in 60 (64.5%), 43 (46.2%), and 38 (40.9%) charts respectively. Variation in the medications used was marked: 54 patients (58%) were started on a single agent and 39 (42%), on multiple agents. The 40 patients (43%) started on midazolam alone received a mean daily dose of 21.4 mg (standard deviation: 24.6 mg). CONCLUSIONS The lack of documentation and standardized practice of ps on our pcu has resulted in a quality improvement program to address those gaps. They also highlight the importance of conducting research and developing clinical guidelines in this area.
Collapse
Affiliation(s)
- M McKinnon
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON
| | - C Azevedo
- Department of Medical Oncology, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal
| | - S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - P Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| | - J Pereira
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON. ; Bruyère Continuing Care, Ottawa, ON. ; Bruyère Research Institute, Ottawa, ON
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW The aim of this review was to present and comment on recent data published on palliative sedation in palliative and end-of-life care. Palliative sedation is a medical procedure used to deal with the refractory symptoms occurring in the advanced stages of cancer. It has clinical, nursing, relational and ethical implications, making it a highly sensitive issue. RECENT FINDINGS Over the last 12 months, a number of authors have published interesting new findings on different areas of palliative sedation, that is prevalence, indications, monitoring, duration and choice of drugs. In particular, a clear definition of palliative sedation and of its more pronounced form, deep continuous sedation (DCS), has emerged. It has been confirmed that, when performed in the correct way and with the right aims, palliative sedation does not have a detrimental impact on survival. SUMMARY Recent findings confirm that palliative sedation is an integral part of a medical palliative care approach and is needed in certain clinical situations. It is a legitimate clinical practice from any ethical point of view. While oncologists should have a basic knowledge of the procedure, its in depth study is a core competency for palliative care physicians.
Collapse
|
15
|
Arevalo JJ, Brinkkemper T, van der Heide A, Rietjens JA, Ribbe M, Deliens L, Loer SA, Zuurmond WWA, Perez RSGM. Palliative sedation: reliability and validity of sedation scales. J Pain Symptom Manage 2012; 44:704-14. [PMID: 22819440 DOI: 10.1016/j.jpainsymman.2011.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/21/2011] [Accepted: 11/29/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Observer-based sedation scales have been used to provide a measurable estimate of the comfort of nonalert patients in palliative sedation. However, their usefulness and appropriateness in this setting has not been demonstrated. OBJECTIVES To study the reliability and validity of observer-based sedation scales in palliative sedation. METHODS A prospective evaluation of 54 patients under intermittent or continuous sedation with four sedation scales was performed by 52 nurses. Included scales were the Minnesota Sedation Assessment Tool (MSAT), Richmond Agitation-Sedation Scale (RASS), Vancouver Interaction and Calmness Scale (VICS), and a sedation score proposed in the Guideline for Palliative Sedation of the Royal Dutch Medical Association (KNMG). Inter-rater reliability was tested with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient. Correlations between the scales using Spearman's rho tested concurrent validity. We also examined construct, discriminative, and evaluative validity. In addition, nurses completed a user-friendliness survey. RESULTS Overall moderate to high inter-rater reliability was found for the VICS interaction subscale (ICC = 0.85), RASS (ICC = 0.73), and KNMG (ICC = 0.71). The largest correlation between scales was found for the RASS and KNMG (rho = 0.836). All scales showed discriminative and evaluative validity, except for the MSAT motor subscale and VICS calmness subscale. Finally, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. CONCLUSION The RASS and KNMG scales stand as the most reliable and valid among the evaluated scales. In addition, the RASS was less time consuming, clearer, and easier to use than the MSAT and VICS. Further research is needed to evaluate the impact of the scales on better symptom control and patient comfort.
Collapse
Affiliation(s)
- Jimmy J Arevalo
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Hui D, Mori M, Parsons HA, Kim SH, Li Z, Damani S, Bruera E. The lack of standard definitions in the supportive and palliative oncology literature. J Pain Symptom Manage 2012; 43:582-92. [PMID: 22104619 PMCID: PMC3818788 DOI: 10.1016/j.jpainsymman.2011.04.016] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 01/10/2023]
Abstract
CONTEXT Multiple organizations have raised concerns about the lack of standard definitions for terminology in the supportive and palliative oncology literature. OBJECTIVES We aimed to determine 1) the frequency of 10 commonly used terms in the supportive and palliative oncology literature, 2) the proportion of articles that provided definitions for each term, and 3) how each term was defined. METHODS We systematically searched MEDLINE, PubMed, PsycINFO, the Cochrane Library, Embase, ISI Web of Science, and Cumulative Index to Nursing and Allied Health Literature for original studies, review articles, and systematic reviews related to palliative care and cancer in the first six months of 2004 and 2009. We counted the number of occurrences for "palliative care," "supportive care," "best supportive care," "hospice care," "terminal care," "end-of-life," "terminally ill," "goals of care," "actively dying," and "transition of care" in each article, reviewed them for the presence of definitions, and documented the journal characteristics. RESULTS Among the 1213 articles found, 678 (56%) were from 2009. "Palliative care" and "end-of-life" were the most frequently used terms. "Palliative care," "end-of-life," and "terminally ill" appeared more frequently in palliative care journals, whereas "supportive care" and "best supportive care" were used more often in oncology journals (P<0.001). Among 35 of 601 (6%) articles with a definition for "palliative care," there were 16 different variations (21 of 35 articles used the World Health Organization definition). "Hospice care" had 13 definitions among 13 of 151 (9%) articles. "Supportive care" and other terms were rarely defined (less than 5% of articles that used the term). CONCLUSION Our findings highlight the lack of definitional clarity for many important terms in the supportive and palliative oncology literature. Standard definitions are needed to improve administrative, clinical, and research operations.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
17
|
Swart SJ, van der Heide A, van Zuylen L, Perez RSGM, Zuurmond WWA, van der Maas PJ, van Delden JJM, Rietjens JAC. Considerations of physicians about the depth of palliative sedation at the end of life. CMAJ 2012; 184:E360-6. [PMID: 22331961 DOI: 10.1503/cmaj.110847] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although guidelines advise titration of palliative sedation at the end of life, in practice the depth of sedation can range from mild to deep. We investigated physicians' considerations about the depth of continuous sedation. METHODS We performed a qualitative study in which 54 physicians underwent semistructured interviewing about the last patient for whom they had been responsible for providing continuous palliative sedation. We also asked about their practices and general attitudes toward sedation. RESULTS We found two approaches toward the depth of continuous sedation: starting with mild sedation and only increasing the depth if necessary, and deep sedation right from the start. Physicians described similar determinants for both approaches, including titration of sedatives to the relief of refractory symptoms, patient preferences, wishes of relatives, expert advice and esthetic consequences of the sedation. However, physicians who preferred starting with mild sedation emphasized being guided by the patient's condition and response, and physicians who preferred starting with deep sedation emphasized ensuring that relief of suffering would be maintained. Physicians who preferred each approach also expressed different perspectives about whether patient communication was important and whether waking up after sedation is started was problematic. INTERPRETATION Physicians who choose either mild or deep sedation appear to be guided by the same objective of delivering sedation in proportion to the relief of refractory symptoms, as well as other needs of patients and their families. This suggests that proportionality should be seen as a multidimensional notion that can result in different approaches toward the depth of sedation.
Collapse
Affiliation(s)
- Siebe J Swart
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Swart SJ, Rietjens JAC, van Zuylen L, Zuurmond WWA, Perez RSGM, van der Maas PJ, van Delden JJM, van der Heide A. Continuous palliative sedation for cancer and noncancer patients. J Pain Symptom Manage 2012; 43:172-81. [PMID: 21925832 DOI: 10.1016/j.jpainsymman.2011.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/29/2011] [Accepted: 04/12/2011] [Indexed: 11/26/2022]
Abstract
CONTEXT Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. OBJECTIVES To study the practice of continuous palliative sedation for both cancer and noncancer patients. METHODS In 2008, a structured questionnaire was sent to 1580 physicians regarding their last patient receiving continuous sedation until death. RESULTS A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported on their last case of continuous sedation (cancer patients: n=282 [76%] and noncancer patients: n=88 [24%]). More often, noncancer patients were older, female, and not fully competent. Dyspnea (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.22, 3.72) and psychological exhaustion (OR=2.64; 95% CI: 1.26, 5.55) were more often a decisive indication for continuous sedation for these patients. A palliative care team was consulted less often for noncancer patients (OR=0.45; 95% CI: 0.21, 0.96). Also, preceding sedation, euthanasia was discussed less often with noncancer patients (OR=0.42; 95% CI: 0.24, 0.73), whereas their relatives more often initiated discussion about euthanasia than relatives of cancer patients (OR=3.75; 95% CI: 1.26, 11.20). CONCLUSION The practice of continuous palliative sedation in patients dying of cancer differs from patients dying of other diseases. These differences seem to be related to the less predictable course of noncancer diseases, which may reduce physicians' awareness of the imminence of death. Increased attention to noncancer diseases in palliative care practice and research is, therefore, crucial as is more attention to the potential benefits of palliative care consultation.
Collapse
Affiliation(s)
- Siebe J Swart
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Facciorusso A, Stanislao M, Fanelli M, Valori VM, Valle G. Ethical issues on defibrillator deactivation in end-of-life patients. J Cardiovasc Med (Hagerstown) 2011; 12:498-500. [PMID: 21610508 DOI: 10.2459/jcm.0b013e3283483724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
20
|
Bruce A, Boston P. Relieving existential suffering through palliative sedation: discussion of an uneasy practice. J Adv Nurs 2011; 67:2732-40. [DOI: 10.1111/j.1365-2648.2011.05711.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
21
|
Seymour J, Rietjens J, Brown J, van der Heide A, Sterckx S, Deliens L. The perspectives of clinical staff and bereaved informal care-givers on the use of continuous sedation until death for cancer patients: The study protocol of the UNBIASED study. BMC Palliat Care 2011; 10:5. [PMID: 21375747 PMCID: PMC3056823 DOI: 10.1186/1472-684x-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 03/04/2011] [Indexed: 11/29/2022] Open
Abstract
Background A significant minority of dying people experience refractory symptoms or extreme distress unresponsive to conventional therapies. In such circumstances, sedation may be used to decrease or remove consciousness until death occurs. This practice is described in a variety of ways, including: 'palliative sedation', 'terminal sedation', 'continuous deep sedation until death', 'proportionate sedation' or 'palliative sedation to unconsciousness'. Surveys show large unexplained variation in incidence of sedation at the end of life across countries and care settings and there are ethical concerns about the use, intentions, risks and significance of the practice in palliative care. There are also questions about how to explain international variation in the use of the practice. This protocol relates to the UNBIASED study (UK Netherlands Belgium International Sedation Study), which comprises three linked studies with separate funding sources in the UK, Belgium and the Netherlands. The aims of the study are to explore decision-making surrounding the application of continuous sedation until death in contemporary clinical practice, and to understand the experiences of clinical staff and decedents' informal care-givers of the use of continuous sedation until death and their perceptions of its contribution to the dying process. The UNBIASED study is part of the European Association for Palliative Care Research Network. Methods/Design To realize the study aims, a two-phase study has been designed. The study settings include: the domestic home, hospital and expert palliative care sites. Phase 1 consists of: a) focus groups with health care staff and bereaved informal care-givers; and b) a preliminary case notes review to study the range of sedation therapy provided at the end of life to cancer patients who died within a 12 week period. Phase 2 employs qualitative methods to develop 30 patient-centred case studies in each country. These involve interviews with staff and informal care-givers closely involved in the care of cancer patients who received continuous sedation until death. Discussion To our knowledge, this is one of the few studies which seek to take a qualitative perspective on clinical decision making surrounding the use of continuous sedation until death and the only one which includes the perspectives of nurses, physicians, as well as bereaved informal care-givers. It has several potential strengths, weaknesses, opportunities and threats associated with the specific design of the study, as well as with the sensitive nature of the topic and the different frameworks for ethical review in the participating countries.
Collapse
Affiliation(s)
- Jane Seymour
- School of Nursing, Midwifery and Physiotherapy, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
| | | | | | | | | | | | | |
Collapse
|
22
|
|
23
|
Stevens MJ, Atkinson C, Broadbent AM. The malignant psoas syndrome revisited: case report, mechanisms, and current therapeutic options. J Palliat Med 2010; 13:211-6. [PMID: 20053159 DOI: 10.1089/jpm.2009.0193] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The malignant psoas syndrome (MPS) is a rare and challenging cancer pain state that is often refractory to rational polymodal analgesic therapy. We describe the first case of cervix cancer-related MPS due to extrinsic psoas muscle infiltration and review the therapeutic trajectory and outcome. The anatomic determinants, pain mechanisms, and current and proposed novel treatment strategies for MPS are discussed.
Collapse
Affiliation(s)
- Mark John Stevens
- Department of Palliative Medicine, Hope Health Care, Sydney, New South Wales, Australia.
| | | | | |
Collapse
|