Approaches to suffering at the end of life: the use of sedation in the USA and Netherlands

"More support, less distress?": Examining the role of social norms in alleviating practitioners' psychological distress in the context of assisted dying services

This study explores how providing assisted dying services affects the psychological distress of practitioners. It investigates the influence of professional norms that endorse such services within their field. Study 1 included veterinarians (N = 137, 75.2% female, Mage = 43.1 years, SDage = 12.7 years), and Study 2 health practitioner students (N = 386, 71.0% female, Mage = 21.0 years, SDage = 14.4 years). In both studies, participants indicated their degree of psychological distress following exposure to scenarios depicting assisted dying services that were relevant to their respective situations. In Study 1, we found that higher willingness to perform animal euthanasia was associated with lower distress, as were supportive norms. In Study 2, a negative association between a greater willingness to perform euthanasia and lower psychological distress occurred only when the provision of such services was supported by professional norms. In conclusion, psychological distress is buffered by supportive professional norms.

Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study

BACKGROUND

The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability.

AIM

To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers.

DESIGN

Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure.

SETTING

European.

PARTICIPANTS

International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation.

RESULTS

A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided.

CONCLUSIONS

This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

Attitudes Toward and Experience With Assisted-Death Services and Psychological Implications for Health Practitioners: A Narrative Systematic Review

A narrative systematic review was conducted to review studies that examine mental health implications of involvement in assisted-death services among health practitioners. Qualitative and quantitative studies were included to understand health practitioners' attitudes and experiences with assisted dying services, as well as to identify the mental health consequences. We identified 18 articles from 1591 articles drawn from seven major scientific databases (i.e., PubMed, MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Scopus). Two raters independently evaluated the exclusion and inclusion decisions of the articles and examined methodological flaws in the selected articles. We found that engagement in assisted death services were not reliably associated with mental health outcomes such as anxiety and moral distress. Both positive and negative outcomes were reported, and psychological outcomes for practitioners were shown to vary based on factors including social support for health practitioners' views; their perceived capacity to care for the patients; and legislation.

A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland

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.

A systematic review of quality improvement initiatives for continuous sedation until death

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.

Psychiatrie, soins palliatifs et de fin de vie : des univers (ir)réconciliables? Le cas de madame Sanchez

Contexte : En psychiatrie, la question d’offrir des soins palliatifs et de fin de vie pour ce qui serait une « condition psychiatrique terminale » ou, plus globalement, de considérer adopter une approche palliative pour des problèmes de santé mentale sévères et persistants constitue encore un tabou. Méthodologie : Cette question est abordée par l’analyse d’un cas effectuée lors d’une consultation en éthique clinique à l’aide de la méthode des scénarios d’Hubert Doucet. Il s’agit de madame Sanchez, une patiente âgée de plus de 90 ans, présentant des troubles psychiatriques, exprimant le désir de mourir par des gestes suicidaires, refusant les traitements proposés, ainsi que refusant de boire et manger. Son histoire clinique est racontée par le filtre de l’accompagnement réflexif offert en éthique clinique aux diverses parties prenantes. Résultats : L’analyse de cas, loin de répondre aux défis posés par le concept des soins palliatifs et de fin de vie en contexte psychiatrique, présente néanmoins une occasion d’en nommer les enjeux éthiques principaux : la souffrance psychique, le refus de manger et de boire ainsi que le refus de traitement, la sédation palliative et l’aide médicale à mourir, les volontés et directives médicales anticipées, ainsi que les défis clinico-organisationnels suscités par la clientèle gérontopsychiatrique. Conclusion : Les défis cliniques et éthiques demeurent nombreux pour les professionnels et les décideurs afin de répondre aux besoins de la clientèle de santé mentale très âgée. Nous appelons à un plus grand développement des connaissances sur ce thème précis.

Sedatives and Sedation at the End of Life in Nursing Homes: A Retrospective Multicenter Cohort Study

OBJECTIVES

There is scarce information about sedation in nursing homes at the end of life. We aimed to assess (1) the use of sedatives generally and "sedatives with continuous effect," based on objective operational criteria, within the last week of life in nursing homes and (2) factors associated with this treatment.

DESIGN

Retrospective cohort study, using the nursing homes' medical records.

SETTING AND PARTICIPANTS

Residents who died in 4 German nursing homes from January 2015 to December 2017 and whose medical records were available (n = 512).

METHODS

Sedatives analyzed were those recommended by guidelines for "palliative sedation": benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. The definition of "sedatives with continuous effect" and doses judged as at least moderately sedating were consented by palliative care clinicians and pharmacists, based on the literature. Descriptive statistics and multivariate logistic regression analysis were performed (R version 3.6.1).

RESULTS

Overall, 110/512 (21%) deceased residents received a sedative at least once during the last week of life, 46/512 (9%) "sedatives with continuous effect." Oral lorazepam was used most frequently. Eleven of 512 (2%) residents received doses judged as at least moderately sedating. The term sedation was not used. Most frequent indications were agitation (58/110; 53%) and anxiety (35/110; 32%); no indication was noted for 36/110 (33%) residents. The resident's involvement in the decision for sedatives was documented in 3/110 (3%). Multivariate logistic regression analysis showed significant associations between use of sedatives and age (OR = 0.94, P < .001) as well as institution (P < .001).

CONCLUSIONS AND IMPLICATIONS

Our data indicate a lower prevalence of sedation compared to international data and considerable differences regarding prevalence between institutions. These differences, potential setting-specific challenges, and need for support measures for consistent best practice of sedation in nursing homes should be further explored.

The involvement of cancer patients in the four stages of decision-making preceding continuous sedation until death: A qualitative study

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.

Physicians' perceptions of suffering in people with dementia at the end of life

OBJECTIVE

Our aim was to describe physicians' perceptions of the suffering of their patients who are dying with dementia, many of whom are incompetent with regard to decision making and have difficulty with communicating about the source of their distress and with identifying related factors.

METHOD

We analyzed data from the nationally representative observational Dutch End-of-Life in Dementia (DEOLD) cohort study (2007-2011), which involved 34 long-term care facilities. A total of 103 physicians completed questionnaires about 330 patients with dementia who had died in a participating facility. Suffering during the last six hours of life was defined as "a patient being disturbed by or aware of symptoms," "suffering until the end or death was a struggle"-all related to objective indicators of lack of comfort. We employed generalized estimating equation models to assess associations of suffering with the characteristics of physicians and patients, the patient's death, and the decision-making process.

RESULTS

In 13.8% of cases, the physician felt that the patient had suffered. An unexpected death and death with pneumonia were strongly (an odds ratios close to 6) associated with suffering, and suffering was also independently associated with the physician's perception of worse quality of end-of-life care, death with cardiovascular disease, a less experienced physician, no palliative sedation, and a younger patient.

SIGNIFICANCE OF RESULTS

Most patients with dementia did not suffer during their final hours of life, according to their physicians. There are a number of factors associated with suffering, among them death with pneumonia and unexpected death. We may not be able to have much influence on death from pneumonia, but quality of care and an unexpected death are reasonable targets for intervention. Earlier identification of the beginning of the dying process would allow time to better prepare for approaching death, which would provide a source of comfort.

Reasons for continuous sedation until death in cancer patients: a qualitative interview study

End-of-life sedation, though increasingly prevalent and widespread, remains a highly debated medical practice in the context of palliative medicine. This qualitative study aims to look more specifically at how health care workers justify their use of continuous sedation until death and which factors they report as playing a part in the decision-making process. In-depth interviews were held with 28 physicians and 22 nurses of 27 cancer patients in Belgium who had received continuous sedation until death in hospitals, palliative care units or at home. Our findings indicate that medical decision-making for continuous sedation is not only based on clinical indications but also related to morally complex issues such as the social context and the personal characteristics and preferences of individual patient and their relatives. The complex role of non-clinical factors in palliative sedation decision-making needs to be further studied to assess which medically or ethically relevant arguments are underlying daily clinical practice. Finally, our findings suggest that in some cases continuous sedation was resorted to as an alternative option at the end of life when euthanasia, a legally regulated option in Belgium, was no longer practically possible.

Anaplastic gliomas: end-of-life care recommendations

Despite multimodal antitumor treatment, all patients with an anaplastic glioma will be confronted with incurability in due course and enter the end-of-life (EOL) phase; the period when the patients' condition declines and tumor-directed treatment is no longer effective. Although palliative care is important in all stages of the disease, it is of utmost importance in the EOL phase. The main goal of palliative care is to improve or maintain the quality of life of the patients and their relatives through the prevention and relief of suffering. This review focuses on different aspects of the EOL phase (symptoms and signs, EOL decision-making, advance care planning, organization of care and caregiver burden) and will provide recommendations to optimize palliative care.

Palliative sedation for intolerable suffering

PURPOSE OF REVIEW

The purpose of this review is to provide an update on palliative sedation in palliative and end-of-life care. Palliative sedation is the medical procedure used to deal with refractory symptoms in advanced cancer patients when all other specific approaches have failed.

RECENT FINDINGS

Palliative sedation, in the strictest sense of the term, is a proportionate (proportionate palliative sedation, PPS) and intrinsically variable procedure used on an individual basis to relieve refractory symptoms in terminally ill patients, without the intention of hastening death. Completely separate from any other end-of-life decision and not intended to hasten death, palliative sedation has been shown not to have a detrimental impact on survival.

SUMMARY

To maintain palliative sedation as a legitimate clinical procedure from any ethical or clinical point of view, it must be limited to the restricted area for which it was conceived, that is, relief from refractory suffering as deemed necessary by a patient and by an experienced palliative care team. In this way, there is no risk of associating palliative sedation with other end-of-life decisions. Close collaboration is needed between oncologists and palliative care physicians for this clinical procedure.

Descriptions by general practitioners and nurses of their collaboration in continuous sedation until death at home: in-depth qualitative interviews in three European countries

CONTEXT

One palliative care approach that is increasingly being used at home for relieving intolerable suffering in terminally ill patients is continuous sedation until death. Its provision requires a multidisciplinary team approach, with adequate collaboration and communication. However, it is unknown how general practitioners (GPs) and home care nurses experience being involved in the use of sedation at home.

OBJECTIVES

To present case-based GP and nurse descriptions of their collaboration, roles, and responsibilities during the process of continuous sedation until death at home in Belgium, The Netherlands, and the U.K.

METHODS

We held in-depth qualitative interviews with 25 GPs and 26 nurses closely involved in the care of 29 adult cancer patients who received continuous sedation until death at home.

RESULTS

We found that, in Belgium and The Netherlands, it was the GP who typically made the final decision to use sedation, whereas in the U.K., it was predominantly the nurse who both encouraged the GP to prescribe anticipatory medication and decided when to use the prescription. Nurses in the three countries reported that they commonly perform and monitor sedation in the absence of the GP, which they reported to experience as "emotionally burdensome."

CONCLUSION

We found variety among the countries studied regarding the decision making and provision of continuous sedation until death at home. These differences, among others, may be the result of different organizational contexts in the three countries such as the use of anticipatory medication in the U.K.

Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries

BACKGROUND

Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses.

METHODS

Qualitative case studies using interviews.

SETTING

Hospitals, the domestic home and hospices or palliative care units.

PARTICIPANTS

In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients.

RESULTS

UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an 'alternative' to euthanasia and whether they sought to follow guidelines or frameworks for practice.

CONCLUSION

This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands.

The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland

OBJECTIVE

Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide.

METHOD

Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective.

RESULTS

The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation.

SIGNIFICANCE OF RESULTS

The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.