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Beauverd M, Mazzoli M, Pralong J, Tomczyk M, Eychmüller S, Gaertner J. Palliative sedation - revised recommendations. Swiss Med Wkly 2024; 154:3590. [PMID: 38579308 DOI: 10.57187/s.3590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
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.
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Affiliation(s)
- Michel Beauverd
- Service de soins palliatifs et de support, Département de médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Martyna Tomczyk
- Institute of Humanities in Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Steffen Eychmüller
- Universitäres Zentrum für Palliative Care (UZP), Inselspital, University Hospital, Bern, Switzerland
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
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Tomczyk M, Andorno R, Jox RJ. Should continuous deep sedation until death be legally regulated in Switzerland? An exploratory study with palliative care physicians. Palliat Care Soc Pract 2023; 17:26323524231219509. [PMID: 38152555 PMCID: PMC10752051 DOI: 10.1177/26323524231219509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Background In Switzerland, continuous deep sedation until death (CDSUD) is not legally regulated and the current clinical practice guidelines on palliative sedation from 2005 do not refer to it. In contrast, in France, a neighbouring country, CDSUD is regulated by a specific law and professional guidelines. International studies show that in culturally polymorphic countries, there are variations in the end-of-life practices between linguistic regions and that a linguistic region shares many cultural characteristics with the neighbouring country. Objectives This study aimed to explore the attitudes of palliative care physicians from the French-speaking part of Switzerland on the question of whether CDSUD should be legally regulated in the country, and to identify their arguments. Our study also aimed to assess whether a hypothetical Swiss law on CDSUD should be similar to the current legal regulation of this practice in France. Design We conducted a multicentre exploratory qualitative study based on face-to-face interviews with palliative care physicians in the French-speaking part of Switzerland. Methods We analysed the interview transcripts using thematic analysis, combining deductive and inductive coding. Results Most of the participants were opposed to having specific legal regulation of CDSUD in Switzerland. Their arguments were diverse: some focused on medical and epistemological aspects of CDSUD, whereas others emphasized the legal inconvenience of having such regulation. None had the opinion that, if CDSUD were legally regulated in Switzerland, the regulation should be similar to that in France. Conclusion This study allows to better understand why palliative care physicians in French-speaking Switzerland may be reluctant to have legal regulation of CDSUD. Further studies covering the whole country would be needed to gain a more complete picture of Swiss palliative care physicians on this question.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Av. de Provence 82, Lausanne CH-1007, Switzerland
| | - Roberto Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Ralf J. Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Jonker LA, Heijltjes MT, Rietjens JAC, van der Heide A, Hendriksen G, van Delden JJM, van Thiel GJMW. Experiences and perceptions of continuous deep sedation: An interview study among Dutch patients and relatives. Health Expect 2023; 27:e13869. [PMID: 37822095 PMCID: PMC10726059 DOI: 10.1111/hex.13869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND The incidence of continuous deep sedation (CDS) has more than doubled over the last decade in The Netherlands, while reasons for this increase are not fully understood. Patients and relatives have an essential role in deciding on CDS. We hypothesize that the increase in CDS practice is related to the changing role of patients and relatives in deciding on CDS. OBJECTIVE To describe perceptions and experiences of patients and relatives with regard to CDS. This insight may help professionals and policymakers to better understand and respond to the evolving practice of CDS. METHODS Qualitative interviews were held with patients and relatives who had either personal experience with CDS as a relative or had contemplated CDS for themselves. RESULTS The vast majority of respondents appreciated CDS as a palliative care option, and none of the respondents reported (moral) objections to CDS. The majority of respondents prioritized avoiding suffering at the end of life. The patients and families generally considered CDS a palliative care option for which they can choose. Likewise, according to our respondents, the decision to start CDS was made by them, instead of the physician. Negative experiences with CDS care were mostly related to loss of sense of agency, due to insufficient communication or information provision by healthcare professionals. Lack of continuity of care was also a source of distress. We observed a variety in the respondents' understanding of the distinction between CDS and other end-of-life care decisions, including euthanasia. Some perceived CDS as hastening death. CONCLUSION The traditional view of CDS as a last resort option for a physician to relieve a patient's suffering at the end of life is not explicit among patients and relatives. Instead, our results show that they perceive CDS as a regular palliative care option. Along with this normalization of CDS, patients and relatives claim a substantial say in the decision-making and are mainly motivated by a wish to avoid suffering and exercise control at the end of life. These distinct views on CDS of patients, their relatives and healthcare providers should be reconciled in guidelines and protocols for CDS. PATIENT OR PUBLIC CONTRIBUTION One of the authors in our team (G. H.) has experience with CDS as a relative and ensured that the patient/relative viewpoint was adequately reflected in the design and conduct of our study. In the preliminary phase of our study, G. H. adjusted the topic list so it was better adapted to the current practice of CDS. During the data analysis, G. H. read several interviews and took part in the open and critical discussion on central themes and core concepts as an important member of the author team, thereby guaranteeing the central position of the patient/relative perspective in our final research outcome.
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Affiliation(s)
- Louise Annemoon Jonker
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of PediatricsDiakonessenhuis UtrechtUtrechtThe Netherlands
| | - Madelon T. Heijltjes
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Judith A. C. Rietjens
- Department of Public Health, Erasmus Medical CenterErasmus UniversityRotterdamThe Netherlands
- Department of Design, Organization and Strategy, Faculty of Industrial Design EngineeringDelft University of TechnologyDelftThe Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical CenterErasmus UniversityRotterdamThe Netherlands
| | - Geeske Hendriksen
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Johannes J. M. van Delden
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ghislaine J. M. W. van Thiel
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
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Mills A, Nolen A, Qureshi F, Selby D. Use of palliative sedation following Medical Assistance in Dying (MAiD) legislation: A mixed-methods study of palliative care providers. Palliat Support Care 2023:1-8. [PMID: 37365818 DOI: 10.1017/s1478951523000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Palliative sedation (PS) and Medical Assistance in Dying (MAiD) are options for end-of-life (EOL) care in Canada, since the latter was legalized in 2016. Little research to date has explored the potential impact of MAiD on PS practices. This study investigated physicians' perceptions of their practices surrounding PS and how they may have changed since 2016. METHODS A survey (n=37) and semi-structured interviews (n=23) were conducted with palliative care providers throughout Ontario. Questions focused on PS practices and explored potential changes following the implementation of MAiD. Codes were determined collaboratively and applied line-by-line by 2 independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated via reflexive thematic analysis. RESULTS Thematic analysis yielded the following themes: (1) Increased patient/family knowledge of EOL care; (2) More frequent/fulsome discussions; (3) Normalization/repositioning of PS; and (4) Conflation and differentiation of PS/MAiD. Across these themes, participants espoused increased patient, family, and provider comfort with PS, which may stem equally from the advent of MAiD and the growth of palliative care in general. Participants also emphasized that, following MAiD, PS is viewed as a less radical intervention. SIGNIFICANCE OF RESULTS This is the first study to investigate physicians' perspectives on the impact of MAiD on PS. Participants strongly opposed treating MAiD and PS as direct equivalents, given the differences in intent and eligibility. Participants stressed that MAiD requests/inquiries should prompt individualized assessments exploring all avenues of symptom management - the results of which may or may not include PS.
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Affiliation(s)
- Anneliese Mills
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amy Nolen
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto, Toronto, Toronto
| | - Fahad Qureshi
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Debbie Selby
- Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto, Toronto, Toronto
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095472. [PMID: 35564867 PMCID: PMC9104501 DOI: 10.3390/ijerph19095472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 02/05/2023]
Abstract
As previous research has paid little attention to environmental factors affecting the practice of continuous deep sedation until death (CDS), we aimed to explore these using physicians’ experiences and perceptions. We performed an interpretative thematic analysis of primary data from a qualitative interview study conducted from February to May 2019 in Belgium with 47 physicians. Structural factors were identified: the lack of professional and/or technical support in monitoring sedated patients; the use of guidelines in team contexts; the time constraints for treating individual patients and work pressure; the structural knowledge gap in medical education; the legal context for assisted dying; and the lack of a clear legal context for CDS. Cultural factors were identified: the moral reservations of care teams and/or institutions towards CDS; the presence of a palliative care culture within care teams and institutions; the culture of fear of making clinical errors regarding CDS among a group of physicians; the professional stigma of performing assisted dying among some of the physician population; the different understandings of CDS in medical and policy fields; and the societal taboo around suffering at the end of life and natural death. To conclude, improving CDS practice requires a whole-system approach considering environmental factors.
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Vieille M, Dany L, Coz PL, Avon S, Keraval C, Salas S, Bernard C. Perception, Beliefs, and Attitudes Regarding Sedation Practices among Palliative Care Nurses and Physicians: A Qualitative Study. Palliat Med Rep 2021; 2:160-167. [PMID: 34223516 PMCID: PMC8241398 DOI: 10.1089/pmr.2021.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Palliative care teams face complex medical situations on a daily basis. These situations require joint reflection and decision making to propose appropriate patient care. Sometimes, sedation is one of the options to be considered. In addition to medical and technical criteria justifying the use of sedation, multiple psychosocial criteria impact the decision making of palliative care teams and guide, give sense to, and legitimize professional practices. Objective: The main goal of this study was to explore perceptions, experiences, and beliefs of palliative care teams about sedation practices in a legislative context (Claeys–Leonetti law, 2016; France), which authorizes continuous deep sedation (CDS) until death. Methods: This is a qualitative study using 28 semistructured interviews with physicians and nurses working in a palliative care team in France (PACA region). All verbal productions produced during interviews were fully transcribed and the contents analyzed. Findings: Content analysis revealed four themes: (1) sedation as a “good death,” (2) emotional experiences of sedations, (3) the practice of CDS, and (4) the ambiguous relationship with the Claeys–Leonetti law. Conclusions: This qualitative study provides evidence of a form of “naturalization” of the practice of sedation. However, the Claeys–Leonetti law exacerbates differences of opinion between palliative caregivers on sedation and questions the interest of this law for society and palliative care practices. clinicalTrials.gov identifier: NCT04016038.
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Affiliation(s)
| | - Lionel Dany
- Aix-Marseille Université, LPS, Aix-en-Provence, France.,APHM, Timone, Service d'Oncologie Médicale, Marseille, France
| | - Pierre Le Coz
- Aix Marseille Université, CNRS, EFS, ADES, Marseille, France
| | - Sophie Avon
- Aix-Marseille Université, LPS, Aix-en-Provence, France
| | | | - Sébastien Salas
- APHM, Timone, Service d'Oncologie Médicale, Marseille, France.,Aix Marseille Université, CRO2, Marseille, France
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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.,Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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Robijn L, Deliens L, Scherrens AL, Pauwels NS, Pype P, Rietjens J, Chambaere K. A systematic review of quality improvement initiatives for continuous sedation until death. Palliat Med 2021; 35:670-682. [PMID: 33722107 DOI: 10.1177/0269216321996990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. AIM To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. DESIGN Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). DATA SOURCES Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. RESULTS Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. CONCLUSIONS The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.
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Affiliation(s)
- Lenzo Robijn
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Anne-Lore Scherrens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Nele S Pauwels
- Ghent University, Knowledge Management Center Ghent, Ghent, Belgium
| | - Peter Pype
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
| | - Judith Rietjens
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Kenneth Chambaere
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-Life Care Research Group, Brussels, Belgium.,Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium.,Ghent University, Department of Public Health and Primary Care, Ghent, Belgium
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Koksvik GH, Richards N, Gerson SM, Materstvedt LJ, Clark D. Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying. Health (London) 2020; 26:512-531. [PMID: 33307828 PMCID: PMC9163770 DOI: 10.1177/1363459320976746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Medicalisation is a pervasive feature of contemporary end of life and dying in Western Europe and North America. In this article, we focus on the relationship between two specific aspects of the medicalisation of dying: deep continuous palliative sedation until death and assisted dying. We draw upon a qualitative interview study with 29 health professionals from three jurisdictions where assisted dying is lawful: Flanders, Belgium; Oregon, USA; and Quebec, Canada. Our findings demonstrate that the relationship between palliative sedation and assisted dying is often perceived as fluid and complex. This is inconsistent with current laws as well as with ethical and clinical guidelines according to which the two are categorically distinct. The article contributes to the literature examining health professionals’ opinions and experiences. Moreover, our findings inform a discussion about emergent themes: suffering, timing, autonomy and control – which appear central in the wider discourse in which both palliative sedation and assisted dying are situated, and which in turn relate to the wider ideas about what constitutes a ‘good death’.
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Robijn L, Deliens L, Rietjens J, Pype P, Chambaere K. Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. THE GERONTOLOGIST 2020; 60:916-925. [PMID: 31850500 DOI: 10.1093/geront/gnz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved. RESEARCH DESIGN AND METHODS Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available. DISCUSSION AND IMPLICATIONS The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
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11
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Rodrigues P, Menten J, Gastmans C. Physicians' perceptions of palliative sedation for existential suffering: a systematic review. BMJ Support Palliat Care 2019; 10:136-144. [PMID: 31481477 DOI: 10.1136/bmjspcare-2019-001865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Paulo Rodrigues
- ETHICS 7446 - Centre d'éthique médicale, Université Catholique de Lille, Lille, France
| | - Johan Menten
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Chris Gastmans
- Interfaculty Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan MA. Using sedative substances until death: A mortality follow-back study on the role of healthcare settings. Palliat Med 2019; 33:213-220. [PMID: 30516090 DOI: 10.1177/0269216318815799] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated. Aim: To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control. Design: National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older. Setting/participants: Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included. Results: Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001). Conclusion: In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.
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Affiliation(s)
- Sarah Ziegler
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Margareta Schmid
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- 2 Clinic for Geriatric Medicine, University Hospital Zurich and Centre on Aging and Mobility, University of Zurich and City Hospital Waid, Zurich, Switzerland
| | - Milo Alan Puhan
- 1 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Abstract
'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.
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14
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Robijn L, Seymour J, Deliens L, Korfage I, Brown J, Pype P, Van Der Heide A, Chambaere K, Rietjens J. The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study. Palliat Med 2018; 32:1198-1207. [PMID: 29667509 DOI: 10.1177/0269216318770342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. AIM To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. DESIGN Qualitative case studies using interviews. SETTING/PARTICIPANTS Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. RESULTS We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician's role was largely limited to evaluating if and when the medical criteria were met. CONCLUSION Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.
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Affiliation(s)
- Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Jane Seymour
- 3 The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Ida Korfage
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Jayne Brown
- 5 School of Nursing and Midwifery, De Montfort University, Leicester, UK.,6 Centre for the Promotion of Excellence in Palliative Care, De Montfort University, Leicester, UK
| | - Peter Pype
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,7 Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Agnes Van Der Heide
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
| | - Kenneth Chambaere
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,2 Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Judith Rietjens
- 4 Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, The Netherlands
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15
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Cohen-Almagor R, Ely EW. Euthanasia and palliative sedation in Belgium. BMJ Support Palliat Care 2018; 8:307-313. [PMID: 29305500 DOI: 10.1136/bmjspcare-2017-001398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/16/2017] [Accepted: 11/22/2017] [Indexed: 12/15/2022]
Abstract
The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.
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Affiliation(s)
| | - E Wesley Ely
- Geriatric Research, VA Tennessee Valley Healthcare System, Education and Clinical Center (GRECC), Nashville, Tennessee, USA.,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee, USA
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16
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Ziegler S, Merker H, Schmid M, Puhan MA. The impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being: a systematic review. BMC Palliat Care 2017; 16:30. [PMID: 28482856 PMCID: PMC5422916 DOI: 10.1186/s12904-017-0205-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/26/2017] [Indexed: 12/01/2022] Open
Abstract
Background The practice of continuous deep sedation is a challenging clinical intervention with demanding clinical and ethical decision-making. Though current research indicates that healthcare professionals’ involvement in such decisions is associated with emotional stress, little is known about sedation-related emotional burden. This study aims to systematically review the evidence on the impact of the inpatient practice of continuous deep sedation until death on healthcare professionals’ emotional well-being. Methods A systematic review of literature published between January 1990 and October 2016 was performed following a predefined protocol. MEDLINE, EMBASE, PubMed, Cochrane Library, CINAHL, Scopus, and PsycINFO were searched using search terms within “end-of-life care”, “sedation”, and “emotional well-being”. Dissertations and reference lists were screened by hand. Two independent reviewers conducted study selection, data extraction and quality assessment. We abstracted measures of psychological outcomes, which were related to the practice of continuous deep sedation until death, including emotional well-being, stress and exhaustion. We used the GRADE approach to rate the quality of evidence. Results Three studies remained out of 528 publications identified. A total of 3′900 healthcare professionals (82% nurses, 18% physicians) from Japan (n = 3384) and the Netherlands (n = 16) were included. The prevalence of sedation-related burden in nurses varied from 11 to 26%, depending on outcome measure. Physicians showed medium levels of emotional exhaustion and low levels of depersonalization. Common clinical concerns contributing to professionals’ burden were diagnosing refractory symptoms and sedation in the context of possibly life-shortening decisions. Non-clinical challenges included conflicting wishes between patients and families, disagreements within the care team, and insufficient professionals’ skills and coping. Due to the limited results and heterogeneity in outcome measure, the GRADE ratings for the quality of evidence were low. Conclusions Current evidence does not suggest that practicing continuous deep sedation is generally associated with lower emotional well-being of healthcare professionals. Higher emotional burden seems more likely when professionals struggled with clinical and ethical justifications for continuous deep sedation. This appeared to be in part a function of clinical experience. Further research is needed to strengthen this evidence, as it is likely that additional studies will change the current evidence base.
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Affiliation(s)
- Sarah Ziegler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.
| | - Hannes Merker
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Margareta Schmid
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland
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17
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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: 25] [Impact Index Per Article: 3.6] [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.
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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
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18
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Robijn L, Cohen J, Rietjens J, Deliens L, Chambaere K. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11:e0158188. [PMID: 27337064 PMCID: PMC4918927 DOI: 10.1371/journal.pone.0158188] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuous deep sedation until death is a highly debated medical practice, particularly regarding its potential to hasten death and its proper use in end-of-life care. A thorough analysis of important trends in this practice is needed to identify potentially problematic developments. This study aims to examine trends in the prevalence and practice characteristics of continuous deep sedation until death in Flanders, Belgium between 2007 and 2013, and to study variation on physicians' degree of palliative training. METHODS Population-based death certificate study in 2007 and 2013 in Flanders, Belgium. Reporting physicians received questionnaires about medical practices preceding the patient's death. Patient characteristics, clinical characteristics (drugs used, duration, artificial nutrition/hydration, intention and consent), and palliative care training of attending physician were recorded. We posed the following question regarding continuous deep sedation: 'Was the patient continuously and deeply sedated or kept in a coma until death by the use of one or more drugs'. RESULTS After the initial rise of continuous deep sedation to 14.5% in 2007 (95%CI 13.1%-15.9%), its use decreased to 12.0% in 2013 (95%CI 10.9%-13.2%). Compared with 2007, in 2013 opioids were less often used as sole drug and the decision to use continuous deep sedation was more often preceded by patient request. Compared to non-experts, palliative care experts more often used benzodiazepines and less often opioids, withheld artificial nutrition/hydration more often and performed sedation more often after a request from or with the consent of the patient or family. CONCLUSION Worldwide, this study is the first to show a decrease in the prevalence of continuous deep sedation. Despite positive changes in performance and decision-making towards more compliance with due care requirements, there is still room for improvement in the use of recommended drugs and in the involvement of patients and relatives in the decision-making process.
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Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Judith Rietjens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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