Dutch physicians on the role of the family in continuous sedation

Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study

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.

Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying

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’.

Attitudes of Professional Caregivers and Family Members Regarding the Use of Monitoring Devices to Improve Assessments of Pain and Discomfort During Continuous Sedation Until Death

CONTEXT

Assessing consciousness and pain during continuous sedation until death (CSD) by behavior-based observational scales alone has recently been put into question. Instead, the use of monitoring technology has been suggested to make more objective and reliable assessments. Insights into which factors influence attitudes toward using these monitoring devices in a context of CSD is a first step in formulating recommendations to inform future practice.

OBJECTIVES

The aim of this study was to find out what influences professional caregivers' and family members' (FMs) attitudes regarding the use of monitors during CSD.

METHODS

We conducted semistructured face-to-face interviews with 20 professional caregivers and 15 FMs, who cared for a patient or had an FM, respectively, who took part in a study using monitoring devices. Recruitment took place in an academic hospital, a locoregional hospital, and two nursing homes, all located in Belgium. Two researchers independently analyzed the data, using grounded theory to inductively develop a model that represents the emerging attitude toward use of monitors during CSD.

RESULTS

Our model shows that the emerging attitudes toward using monitors during CSD is determined by view on CSD, desire for peace of mind, emotional valence attached to using monitors, and the realization that the sole use of behavior-based observational measures could be unreliable in a CSD context. We identified several facilitators and barriers to inform future implementation strategies.

CONCLUSION

Most participants had no objections, and all participants found the use of monitoring devices during CSD feasible and acceptable. We identified a number of facilitators and barriers and suggested that being aware that care can be improved, good communication, shared decision making, and continuing professional education can overcome the identified barriers. We suggest future research would focus on developing implementation strategies and guidelines for introducing objective monitoring devices in diverse palliative care settings.

Real and illusory perceptions of patients in induced coma

OBJECTIVE

To identify, in the scientific literature, real and illusory perceptions of adult patients in induced coma.

METHODS

This is an integrative review of 15 primary studies from the Medline, Web of Science, LILACS, CINAHL and SCOPUS databases.

RESULTS

The main memories reported after induced coma were thirst, cold, and pain. In some studies, patients reported they were unable to tell whether they were awake or dreaming, whether it was real or unreal. Satisfactory memories were reported by patients related to the care received and the use of bedside journals.

CONCLUSION

Evidence showed a number of studies aiming to identify delirium, but without a focus on analyzing real or illusory perceptions of patients after induced coma. Thus, this integrative review identified scientific evidence of memories related to perceptions of sedated patients in the intensive care unit.

Caregivers' Experiences With Medical Aid-In-Dying in Vermont: A Qualitative Study

CONTEXT

Eight jurisdictions in the U.S. currently permit medical aid-in-dying (AID), yet little is known about the direct experience of caregivers in supporting a loved one through the process.

OBJECTIVES

To explore the experiences of lay caregivers involved with AID in the U.S., focusing on the day of death.

METHODS

Semistructured in-depth interviews were conducted with caregivers of terminally ill patients who pursued AID under Vermont's 2013 "Patient Choice and Control at End of Life" Act. Deidentified interview transcripts were analyzed using an inductive iterative approach.

RESULTS

The final sample included 19 caregivers who had cared for a total of 11 patients. Most caregivers were females (89%), and more than half were close friends. Their mean age was 60.3. Social support provided by caregivers on the day of an AID death fell into two broad categories: emotional and instrumental. These overarching forms of support were further distributed between four distinct temporal phases: preparation, ingestion, waiting, and after death.

CONCLUSION

Although AID is often presented as a simple matter of individual choice and autonomy, most patients who pursue it do so with tremendous support from caregivers, who are in turn deeply implicated, socially and morally, in the process. Including caregivers in education and planning, where warranted, can mitigate feelings of unpreparedness and ensure a smoother experience for everyone involved.

The impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being: a systematic review

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.

French laypeople's and health professionals' views on the acceptability of terminal sedation

AIM

To study the views on the acceptability of terminal sedation (TS) of laypeople and health professionals in France.

METHOD

In November 2013-June 2015, 223 laypeople and 53 health professionals (21 physicians and 32) judged the acceptability of TS in 48 realistic scenarios composed of all combinations of four factors: (a) the patients' life expectancy, (b) their request for sedation, (c) the decision-making process and (d) the type of sedation. In all scenarios, the patients were women with a terminal illness suffering from intractable pain and receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance.

RESULTS

Five qualitatively different positions were found that were termed TS acceptable if decision taken collectively (15%), TS acceptable if patient explicitly requested it (19%), TS acceptable if patient did not explicitly oppose it (47%), 24-hour sedation not acceptable (6%) and TS always acceptable (13%). The percentage of older participants in the 'always acceptable' cluster was higher than the percentage of younger participants.

CONCLUSIONS

Laypeople and health professionals do not appear to be systematically opposed to TS. The most important factors in increasing its acceptability were the patients' request for sedation and the collective character of the decision-making process.