European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care

The Attitudes and Experiences of Hospice Nurses Regarding Palliative Sedation: A Cross-Sectional Descriptive Study

Background: Despite the global acceptance of palliative sedation, China's engagement in this field remains comparatively restricted. There exists a scarcity of information regarding the attitudes and experiences of hospice nurses concerning palliative sedation. Objectives: This survey aimed at investigating the attitudes of Chinese hospice nurses toward palliative sedation, as well as their practices in palliative sedation. Design: A cross-sectional descriptive study. Setting/Subjects: In 2023, the survey on palliative sedation was introduced during the opening ceremony of the largest National Symposium on New Advances in Hospice Nursing in China. Subsequently, the study questionnaire was disseminated through email to a cohort of 806 hospice nurses attending the conference. Measurements/Results: The statistical analysis was based on 641 valid responses. Among them, 508 had no experience with palliative sedation, while only 133 had such experience. Around 92.5% of hospice nurses with experience in palliative sedation agreed with the physician's instructions to begin palliative sedation. Nurses were present at the start of sedation in nearly all cases (97.0%), and most doctors (79.7%) and family members (82.0%) were also present. However, 8.3% of them perceived that there was no difference between palliative sedation and euthanasia. Furthermore, 13.5% of participants believed that the purpose of palliative sedation was to hasten death. Conclusions: Hospice nurses play a crucial role in the process of palliative sedation, yet they also face significant challenges. It suggests that there is an urgent need in China for the development of consensus or guidelines for palliative sedation to clarify the roles of team members, including hospice nurses.

Acceptance of euthanasia by students of selected study disciplines at universities in Lublin, Poland

BACKGROUND

In the context of discussions between supporters and opponents of euthanasia, and legal regulations regarding this type of practices, the attitude of young people with respect to this phenomenon is a very interesting issue. According to Polish law, euthanasia is prohibited. The aim of this study was to determine the degree of acceptance of euthanasia among students from Polish universities across three different fields of study: psychology, medicine, and economic-technical disciplines, and to identify the factors associated with the acceptance of this phenomenon.

METHODS

The study included 627 persons studying in Lublin, Poland: medicine (280), psychology (170), and economic-technical studies (177). The study was conducted as a survey using questionnaire containing items concerning students' attitudes towards euthanasia. The analysis of the collected data was conducted using the SPSS software (version 29) with the following methods: Chi2, Student's t-test, Phi test, Cramer's V test, Kolmogorov-Smirnov test, one-way ANOVA with Dunnett's post hoc test, linear regression analysis, and categorical regression analysis using optimal scaling (CATREG).

RESULTS

Nearly half of the students participating in the study (45.9%) rated the practice of euthanasia as decidedly negative. The highest number of strongly negative evaluations was found among psychology students, and the least among students of economic-technical disciplines. The level of acceptance of euthanasia is significantly associated with religious involvement and studying psychology. Being religious and being a psychology student both contribute to lower acceptance of euthanasia and a lower willingness to consent to euthanasia. Consent to euthanasia is more commonly declared by individuals with experience of living with elderly people.

CONCLUSIONS

Although nearly half of the respondents expressed a negative attitude towards euthanasia, considering the secularization process among Polish youth, it can be assumed that the level of acceptance of euthanasia in this social group will increase. The lower level of acceptance of euthanasia among psychology and medical students compared to students of economic-technical disciplines suggests that the curricula of these studies present alternative solutions to the problems of terminally ill patients other than euthanasia.

Report on palliative sedation medication usage: a survey of palliative care experts in Eight European countries

BACKGROUND

The practice of palliative sedation continues to raise ethical questions among people, which in turn leads to its varied acceptance and practice across regions. As part of the Palliative Sedation European Union (EU) project, the aim of the present study was to determine the perceptions of palliative care experts regarding the practice of palliative sedation in eight European countries (The Netherlands, Belgium, Germany, UK, Italy, Spain, Hungary, and Romania).

METHODS

A specifically designed survey, including questions on the most frequently used medications for palliative sedation, their availability per countries and settings, and the barriers and facilitators to the appropriate practice of palliative sedation was sent to expert clinicians involved and knowledgeable in palliative care in the indicated countries. A purposive sampling strategy was used to select at least 18 participating clinicians per consortium country. Descriptive statistical analysis was conducted on the survey data.

RESULTS

Of the 208 expert clinicians invited to participate, 124 participants completed the survey. Midazolam was perceived to be the most frequently used benzodiazepine in all eight countries. 86% and 89% of expert clinicians in Germany and Italy, respectively, perceived midazolam was used "almost always", while in Hungary and Romania only about 50% or less of the respondents perceived this. Levomepromazine was the neuroleptic most frequently perceived to be used for palliative sedation in the Netherlands, Spain, Germany, and the United Kingdom. Between 38- 86% of all eight countries´ expert clinicians believed that opioid medications were "almost always" used during palliative sedation. The perceived use of IV hydration and artificial nutrition "almost always" was generally low, while the country where both IV hydration and artificial nutrition were considered to be "very often" given by a third of the expert clinicians, was in Hungary, with 36% and 27%, respectively.

CONCLUSIONS

Our study provides insight about the differences in the perceived practice of medication during palliative sedation between eight European countries. In countries where palliative care services have been established longer perceptions regarding medication use during palliative sedation were more in line with the recommended European guidelines than in Central and Eastern European countries like Romania and Hungary.

Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

How should respiratory depression and loss of airway patency be handled during initiation of palliative sedation?

BACKGROUND

Loss of airway patency has been reported during initiation of palliative sedation. In present guidelines the loss of airway patency during initiation of palliative sedation is not addressed. Airway patency can be restored by jaw thrust/chin lift or placing the patient in the recovery position.

AIM

A structured ethical analysis of how respiratory depression and loss of airway patency during initiation of palliative sedation should be handled. The essence of the dilemma is whether it is appropriate to apply simple non-invasive methods to restore airway patency in order to avoid the patient's immediate death.

DESIGN

A structured analysis based on the four principles of healthcare ethics and stakeholders' interests.

RESULTS

Beneficence and autonomy support a decision not to regain airway patency whereas non-maleficence lends weight to a decision to restore airway patency. Whether the proportionality criterion of the principle of double effect is met depends on the features of the individual case. The ethical problem appears to be a genuine dilemma where important values and arguments point to different conclusions.

CONCLUSION

Whether to restore airway patency when the airway is obstructed during initiation of palliative sedation will ultimately be based on clinical judgment taking into account both any known patient preferences and relevant clinical information. There are strong arguments favoring both options in this clinical and ethical dilemma. The fact that a clear and universal recommendation cannot be made does not imply indifference regarding what is the clinically and ethically best option for each individual patient.

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

BACKGROUND

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

AIM

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

DESIGN

We conducted a qualitative study based on focus group discussions.

SETTING/PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Misconception between palliative care and euthanasia among Thai general practitioners: a cross-sectional study

BACKGROUND

Palliative care lower medical expenses and enhances quality of life, but misconception with euthanasia delays timely care and makes inappropriate patient management.

OBJECTIVE

To examine the magnitude of misconceptions between palliative care and euthanasia among Thai general practitioners, explore the association with knowledge, attitudes, and practical experience, and assess the association between misconception and confidence in practicing and referring patients to palliative care centers.

METHODS

All 144 general practitioners who were going to start residency training at Maharaj Nakorn Chiang Mai Hospital in 2021 participated in this observational cross-sectional study. A chi-square test was utilized to examine the relationship between misconception and knowledge, attitude, practical experience, confidence to practice, and confidence to refer patients. Multivariable logistic regression was carried out while controlling for age, sex, knowledge, attitude, and experience to examine the relationship between misconception and confidence to practice and refer patients for palliative care. Statistical significance was defined at p < 0.05.

RESULTS

About 41% of general physicians had misconceptions regarding palliative care and euthanasia. High knowledge was associated with a lower level of misconception (p = 0.01). The absence of misconceptions was weakly associated with a higher level of confidence in practicing palliative care, with an adjusted odds ratio of 1.51 (95% confidence interval 0.73 to 3.10, p = 0.07).

CONCLUSION

High misconception rates between palliative care and euthanasia among young Thai physicians might impact their confidence in delivering palliative care. Training initiatives for medical students and practitioners can mitigate misconceptions, fostering better palliative care utilization in Thailand.

End-of-life Comfort Evaluation, is Clinic Enough? A Retrospective Cohort Study of Combined Comfort Evaluation with Analgesia/Nociception Index and Clinic in non-Communicative Patients

Background: Comfort evaluation is one of the major challenges in the palliative care setting, particularly when it comes to non-communicative patients. For this specific population, validated tools for comfort evaluation are scarce and healthcare professionals have to rely on their clinical sense and experience. Objectives: To provide arguments for the use of Analgesia/Nociception Index (ANI) monitoring in order to improve clinical comfort evaluation. Methods: We conducted a retrospective cohort study of non-communicative patients at the end of their lives whose comfort was evaluated clinically and with ANI. We focused on the coherence or discordance of clinical and ANI evaluations and on pharmacological interventions driven by them. Results: 58 evaluations from 33 patients were analyzed. Clinical and demographic characteristics were highly variable. Simultaneous clinical and ANI evaluations were concordant in 45 measurements (77.58%), leading mostly to no treatment modification when indicating comfort and to increasing anxiolytic or pain-relief treatments when indicating discomfort. Thirteen (22.41%) evaluations were discordant, leading mostly to treatment incrementation. Conclusion: We suggest that the ANI monitor is a reliable tool in the palliative setting and may help provide patients with the best symptom relief and the most appropriate therapeutics.

Terminological Confusion About Sedation in Palliative Care: Results of an International Online Vignette Survey

Background: Terminological problems concerning sedation in palliative care and consequences for research and clinical decision making have been reported frequently. Objectives: To gather data on the application of definitions of sedation practices in palliative care to clinical cases and to analyze implications for high-quality definitions. Design: We conducted an online survey with a convenience sample of international experts involved in the development of guidelines on sedation in palliative care and members of the European Association for Palliative Care (EAPC). Participants were asked to apply four published definitions to four case vignettes. Data were analyzed using descriptive statistics. Results: A total of 32 experts and 271 EAPC members completed the survey. The definitions were applied correctly in n = 2200/4848 cases (45.4%). The mean number of correct applications of the definitions (4 points max.) was 2.2 ± 1.14 for the definition of the SedPall study group, 1.8 ± 1.03 for the EAPC definition, 1.7 ± 0.98 for the definition of the Norwegian Medical Association, and 1.6 ± 1.01 for the definition of the Japanese Society of Palliative Medicine. The rate of correct applications for the 16 vignette-definition pairs varied between 70/303 (23.1%) and 227/303 (74.9%). The content of definitions and vignettes together with free-text comments explains participants' decisions and misunderstandings. Conclusions: Definitions of sedation in palliative care are frequently incorrectly applied to clinical case scenarios under simplified conditions. This suggests that clinical communication and research might be negatively influenced by misunderstandings and inconsistent labeling or reporting of data. Clinical Trial Registration Number: DRKS00015047.

Continuous Deep Sedation Until Death of Children at the End of Life: French Physicians' Opinions

Objectives: To evaluate physicians' opinions concerning continuous deep sedation until death (CDSUD) and implementation of Claeys-Leonetti; a law intended to be applicable to all patients, but without a specific framework for children thus giving rise to ethically and legally complex situations. The secondary objective was to identify if physicians' characteristics could influence their opinions. Study Design: This was a national, multicenter, noninterventional cross-sectional survey from January 30, 2020, until March 1, 2020. The target population consisted of French physicians involved in children's end-of-life situations. The validated questionnaire explored respondents' characteristics and their opinions on four hypothetical pediatric clinical cases. Results: Analysis was conducted on 391 respondents. The oncological situation was more easily recognized as end of life compared with the neurological pathology (77% vs. 40.4%). Dependence on mechanical ventilation was another major factor influencing physicians in identifying end-of-life situations. Physicians clearly recognized the difference in intention between CDSUD and euthanasia. They accepted to implement CDSUD more easily in newborns. The withdrawal of artificial nutrition and hydration gave rise to divergent opinions. Respondents were in favor of adolescents' decision-making autonomy and their access to drafting advance directives. The child's best interest prevailed in case of objection by parents, except in situations outside the law's framework or in cases of disagreement within the health care team. Conclusion: Results of our study showed differences in the interpretation of the law concerning the CDSUD application framework and provide elements for reflection, which may ultimately contribute to the development of specific guidelines in CDSUD in children at the end of life.

Addressing Challenges With Sedation in End-of-Life Care

In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.

Noninvasive monitoring technologies to identify discomfort and distressing symptoms in persons with limited communication at the end of life: a scoping review

BACKGROUND

Discomfort and distressing symptoms are common at the end of life, while people in this stage are often no longer able to express themselves. Technologies may aid clinicians in detecting and treating these symptoms to improve end-of-life care. This review provides an overview of noninvasive monitoring technologies that may be applied to persons with limited communication at the end of life to identify discomfort.

METHODS

A systematic search was performed in nine databases, and experts were consulted. Manuscripts were included if they were written in English, Dutch, German, French, Japanese or Chinese, if the monitoring technology measured discomfort or distressing symptoms, was noninvasive, could be continuously administered for 4 hours and was potentially applicable for bed-ridden people. The screening was performed by two researchers independently. Information about the technology, its clinimetrics (validity, reliability, sensitivity, specificity, responsiveness), acceptability, and feasibility were extracted.

RESULTS

Of the 3,414 identified manuscripts, 229 met the eligibility criteria. A variety of monitoring technologies were identified, including actigraphy, brain activity monitoring, electrocardiography, electrodermal activity monitoring, surface electromyography, incontinence sensors, multimodal systems, and noncontact monitoring systems. The main indicators of discomfort monitored by these technologies were sleep, level of consciousness, risk of pressure ulcers, urinary incontinence, agitation, and pain. For the end-of-life phase, brain activity monitors could be helpful and acceptable to monitor the level of consciousness during palliative sedation. However, no manuscripts have reported on the clinimetrics, feasibility, and acceptability of the other technologies for the end-of-life phase.

CONCLUSIONS

Noninvasive monitoring technologies are available to measure common symptoms at the end of life. Future research should evaluate the quality of evidence provided by existing studies and investigate the feasibility, acceptability, and usefulness of these technologies in the end-of-life setting. Guidelines for studies on healthcare technologies should be better implemented and further developed.

Palliative sedation - revised recommendations

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

Practices of and Perspectives on Palliative Sedation Among Palliative Care Physicians in Ontario, Canada: A Mixed-Methods Study

Background

Palliative sedation (PS) is a therapeutic intervention employed to manage severe and refractory symptoms in terminally ill patients at end of life. Inconsistencies in PS practice guidelines coupled with clinician ambiguity have resulted in confusion about how PS is best integrated into practice. Understanding the perspectives, experiences, and practices relating to this modality will provide insight into its clinical application and challenges within the palliative care landscape.

Objective

The aim is to explore the perspectives of palliative care physicians administering PS, including how practitioners define PS, factors influencing decision making about the use of PS, and possible reasons for changes in practice patterns over time.

Methods

A survey (n = 37) and semistructured interviews (n = 23) were conducted with palliative care physicians throughout Ontario. Codes were determined collaboratively and applied line-by-line by two independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated through reflexive thematic analysis.

Results

Five key themes were identified: (1) lack of standardization, (2) differing definitions, (3) logistical challenges, (4) perceived "back-up" to Medical Assistance in Dying, and (5) tool of the most responsible physician.

Conclusion

There was significant variability in how participants defined PS and in frequency of use of PS. Physicians described greater ease implementing PS when practicing in palliative care units, with significant barriers faced by individuals providing home-based palliative care or working as consultants on inpatient units. Educational efforts are required about the intent and practice of PS, particularly among inpatient interprofessional teams.

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.

Palliative care physicians' decision-making about palliative sedation for existential suffering: A Belgian nationwide qualitative study

OBJECTIVES

This study aims to provide an in-depth understanding of the content and process of decision-making about palliative sedation for existential suffering (PS-ES) as perceived by Belgian palliative care physicians.

METHODS

This Belgian nationwide qualitative study follows a grounded theory approach. We conducted semistructured interviews with 25 palliative care physicians working in 19 Belgian hospital-based palliative care units and 4 stand-alone hospices. We analyzed the data using the Qualitative Analysis Guide of Leuven, and we followed the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ).

RESULTS

Analysis of the data identified several criteria that physicians apply in their decision-making about PS-ES, namely, the importance of the patient's demand, PS-ES as a last resort option after all alternatives have been applied, the condition of unbearable suffering combined with other kinds of suffering, and the condition of being in a terminal stage. Regarding the process of decision-making itself, physicians refer to the need for multidisciplinary perspectives supported by an interpretative dialogue with the patient and all other stakeholders. The decision-making process involves a specific temporality and physicians' inner conviction about the need of PS-ES.

SIGNIFICANCE OF RESULTS

Belgian palliative care physicians are not sure about the criteria regarding decision-making in PS-ES. To deal with complex existential suffering in end-of-life situations, they stress the importance of participation by all stakeholders (patient, relatives, palliative care team, other physicians, nurses, social workers, physiotherapists, occupational therapists, chaplains, etc.) in the decision-making process to prevent inadequate decisions being made.

Intentions at the End of Life: Continuous Deep Sedation and France's Claeys-Leonetti law

In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its implications for the intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life.

Palliative sedation determinants: systematic review and meta-analysis in palliative medicine

BACKGROUND

The utilisation of palliative sedation is often favoured by patients approaching end of life due to the presence of multiple difficult-to-manage symptoms during the terminal stage. This study aimed to identify the determinants of the use of palliative sedation.

METHODS

To identify pertinent observational studies, a comprehensive search was performed in PubMed, Embase, Cochrane Library, and PsycINFO databases from their inception until March 2022. The methodological quality of the chosen prospective and retrospective cohort studies was assessed using the Newcastle Ottawa Scale, while the Agency for Healthcare Research and Quality was used to evaluate the methodological quality of the selected cross-sectional studies. For each potential determinant of interest, the collected data were synthesised and analysed, and in cases where data could not be combined, a narrative synthesis approach was adopted.

RESULTS

A total of 21 studies were analysed in this research, consisting of 4 prospective cohort studies, 7 retrospective cohort studies, and 10 cross-sectional studies. The findings indicated that several determinants were significantly associated with palliative sedation. These determinants included younger age, male gender, presence of tumours, dyspnoea, pain, delirium, making advanced medical end-of-life decisions, and dying in a hospital setting.

CONCLUSIONS

The findings of our review could help physicians identify patients who may need palliative sedation in advance and implement targeted interventions to reverse refractory symptoms, develop personalized palliative sedation programs, and ultimately improve the quality of palliative care services.

TRIAL REGISTRATION

PROSPERO registration number CRD42022324720.

Ought the level of sedation to be reduced during deep palliative sedation? A clinical and ethical analysis

BACKGROUND

Deep palliative sedation (DPS) is applied as a response to refractory suffering at the end of life when symptoms cannot be relieved in an awake state. DPS entails a dilemma of whether to provide uninterrupted sedation-in which case DPS would turn into deep and continuous palliative sedation (DCPS) -to minimise the risk that any further intolerable suffering will occur or whether to pause sedation to avoid unnecessary sedation. DPS is problematic in that it leaves the patient 'socially dead' by eradicating their autonomy and conscious experiences.

AIM

To perform a normative ethical analysis of whether guidelines should recommend attempting to elevate consciousness during DPS.

DESIGN

A structured analysis based on the four principles of healthcare ethics and consideration of stakeholders' interests.

RESULTS

When DPS is initiated it reflects that symptom relief is valued above the patient's ability to exercise autonomy and experience social interaction. However, if a decrease in symptom burden occurs, waking could be performed without patients experiencing suffering. Such pausing of deep sedation would satisfy the principles of autonomy and beneficence. Certain patients require substantial dose increases to maintain sedation. Waking such patients risks causing distressing symptoms. This does not happen if deep sedation is kept uninterrupted. Thus, the principle of non-maleficence points towards not pausing sedation. The authors' clinical ethics analysis demonstrates why other stakeholders' interests do not appear to override arguments in favour of providing uninterrupted sedation.

CONCLUSION

Stopping or pausing DPS should always be considered, but should not be routinely attempted.

Dexmedetomidine for end of life sedation: retrospective cohort comparison study

OBJECTIVES

Infused sedatives are often utilised to alleviate distress at the end of life. Which sedative best achieves this is unknown. This study compares breakthrough medication requirements of patients treated with the novel agent dexmedetomidine compared with patients treated with standard-care sedatives.

METHODS

A retrospective cross-cohort comparison. Two studies of patients at the end of life under sedation at the same palliative care unit, one utilising novel sedatives, and the other standard care were compared. Breakthrough medication requirements were compared using paired t-tests, including opioids, benzodiazepines and anticholinergics. Changes in background infusions were compared.

RESULTS

The dexmedetomidine cohort required less breakthrough interventions per day compared with the standard care group, the reduction was significant (2.2 vs 3.9, p=0.003). There was a significant difference in benzodiazepine requirements, with the dexmedetomidine cohort requiring fewer doses per day than the standard care cohort (1.1 vs 0.6, p=0.03). Anticholinergics were more commonly utilised in the standard care cohort but there was no significant difference (p=0.22). Opioid requirements were similar across cohorts with comparable rates of breakthrough use and infusion increases.

CONCLUSIONS

This study demonstrates a reduction in breakthrough medication requirements, particularly benzodiazepines, for patients sedated with dexmedetomidine at end of life.

Sedation practices in palliative care services across France: a nationwide point-prevalence analysis

OBJECTIVES

Terminally ill patients may require sedation to relieve refractory suffering. The prevalence and modalities of this practice in palliative care services remain unclear. This study estimated the prevalence of all sedation leading to a deep unconsciousness, whether transitory, with an undetermined duration, or maintained until death, for terminally ill patients referred to a home-based or hospital-based palliative care service.

METHODS

We conducted a national, multicentre, observational, prospective, cross-sectional study. In total, 331 centres participated, including academic/non-academic and public/private institutions. The participating institutions provided hospital-based or home-based palliative care for 5714 terminally ill patients during the study.

RESULTS

In total, 156 patients received sedation (prevalence of 2.7%; 95% CI, 2.3 to 3.2); these patients were equally distributed between 'transitory', 'undetermined duration' and 'maintained until death' sedation types. The prevalence was 0.7% at home and 8.0% in palliative care units. The median age of the patients was 70 years (Q1-Q3: 61-83 years); 51% were women and 78.8% had cancers. Almost all sedation events occurred at a hospital (90.4%), mostly in specialised beds (74.4%). In total, 39.1% of patients were unable to provide consent; only two had written advance directives. A collegial procedure was implemented in 80.4% of sedations intended to be maintained until death. Midazolam was widely used (85.9%), regardless of the sedation type.

CONCLUSIONS

This nationwide study provides insight into sedation practices in palliative care institutions. We found a low prevalence for all practices, with the highest prevalence among most reinforced palliative care providers, and an equal frequency of all practices.

Palliative sedation in paediatric solid tumour patients: choosing the best drugs

OBJECTIVES

Cancer remains the leading cause of mortality by disease in childhood in high-income countries. For terminally ill children, care focuses on quality of life, and patient management fundamentally affects grieving families. This paper describes our experience of palliative sedation (PS) for children with refractory symptoms caused by solid tumours, focusing on the drugs involved.

METHODS

We retrospectively collected data on all children treated for cancer who died at the pediatric oncology unit of the Fondazione IRCCS Istituto Nazionale dei Tumori between January 2016 and December 2020.

RESULTS

Of the 29 patients eligible for the study, all but 4 received PS. Midazolam was always used, combined in 16 cases with other drugs (mainly classic neuroleptics, alpha-2 agonists and antihistamines). Throughout the period of PS and on the day of death, patients with sarcoma were given higher doses of midazolam and morphine, and more often received combinations of drugs than patients with brain tumours. Sarcoma causes significant symptoms, while brain tumours require less intensive analgesic-sedative therapies because they already impair a patient's state of consciousness.

CONCLUSIONS

Optimising pharmacological treatments demands a medical team that knows how drugs (often developed for other indications) work. Emotional and relational aspects are important too, and any action to lower a patient's consciousness should be explained to the family and justified. Parents should not feel like helpless witnesses. Guidelines on PS in paediatrics could help, providing they acknowledge that a child's death is always a unique case.

Palliative sedation: ethics in clinical practice guidelines - systematic review

OBJECTIVES

The objective of our study was to determine whether, and to what degree, the ethical dimension was present in clinical practice guidelines (CPGs) on palliative sedation, and to identify the ethical issues with respect to the different forms of this practice. The purpose was purely to be descriptive; our aim was not to make any kind of normative judgements on these ethical issues or to develop our own ethical recommendations.

METHODS

We performed a systematic review of CPGs on the palliative sedation of adults, focusing our analysis on the ethical dimension of these texts and the ethical issues of this practice. The study protocol is registered on PROSPERO.

RESULTS

In total, 36 current CPGs from four continents (and 14 countries) were included in our analysis. Generally, ethics was rarely referred to or absent from the CPGs. Only six texts contained a specific section explicitly related to ethics. Ethical issues were named, conceptualised and presented in heterogeneous, often confusing ways. It was impossible to identify the ethical issues of each form of palliative sedation. Ethics expertise was not involved in the development of most of the CPGs and, if it was, this did not always correlate with the ethical dimension of the document.

CONCLUSIONS

Effective cooperation between palliative care clinicians and ethicists should be encouraged, in order to integrate in particular the crucial ethical issues of continuous deep sedation until death when developing or updating CPGs on palliative sedation.

Pain management in German hospices: a cross-sectional study

BACKGROUND AND OBJECTIVES

Pain management is a necessary component of palliative care as most patients suffer from pain during the final phase of life. Due to the complex causation of pain in the last phase of life, it is important to utilize methods other than pharmacotherapeutic options in order to achieve adequate pain control. As little is known about treatment of pain in German hospices, a nationwide survey was conducted.

MATERIALS AND METHODS

All German hospices (259) were contacted by post in June 2020 and asked to participate in an anonymous cross-sectional survey.

RESULTS

A total of 148 (57%) German hospices took part in the survey. A broad variety of medication is used in the hospice setting. Metamizole is the most commonly used non-opiod analgesic , hydromorphone the most commonly used opioid, and pregabalin is the most commonly prescribed co-analgesic drug. The pain medication is usually prescribed as an oral slow-release substance. Standardized treatment schemes are rare among the responding hospices. Most of the respondents also use complementary treatment options, such as aroma (oil) therapy or music therapy, in the treatment of pain. Palliative sedation is used by nearly all responding hospices if all other treatment options fail.

CONCLUSION

This survey provides an overview of the treatment options for pain management in German hospices. A broad variety of pain medication is used. Compared to international literature, it is debatable whether such a large variety of different types of pain medication is necessary, or whether a reduction in the type of medication available and the use of standardized treatment schemes could benefit everyone involved.

Should continuous deep sedation until death be legally regulated in Switzerland? An exploratory study with palliative care physicians

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.

Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit

BACKGROUND

The Richmond Agitation-Sedation Scale - Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient's level of agitation or sedation. The objective of this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process.

METHODS

Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey.

RESULTS

The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs.

CONCLUSION

Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.

Continuous Deep Sedation for Psycho-Existential Suffering: A Multicenter Nationwide Study

Background: There is ongoing debate on whether continuous deep sedation (CDS) for psycho-existential suffering is appropriate. Objective: We aimed to (1) clarify clinical practice of CDS for psycho-existential suffering and (2) assess its impact on patients' survival. Methods: Advanced cancer patients admitted to 23 palliative care units in 2017 were consecutively enrolled. We compared patients' characteristics, CDS practices, and survival between those receiving CDS for psycho-existential suffering ± physical symptoms and only for physical symptoms. Results: Of 164 patients analyzed, 14 (8.5%) received CDS for psycho-existential suffering ± physical symptoms and only one of them (0.6%) solely for psycho-existential suffering. Patients receiving CDS for psycho-existential suffering, compared with those only for physical symptoms, were likely to have no specific religion (p = 0.025), and desired (78.6% vs. 22.0%, respectively; p < 0.001) and requested a hastened death more frequently (57.1% vs. 10.0%, respectively; p < 0.001). All of them had a poor physical condition with limited estimated survival, and mostly (71%) received intermittent sedation before CDS. CDS for psycho-existential suffering caused greater physicians' discomfort (p = 0.037), and lasted for longer (p = 0.029). Dependency, loss of autonomy, and hopelessness were common reasons for psycho-existential suffering that required CDS. The survival time after CDS initiation was longer in patients receiving it for psycho-existential suffering (log-rank, p = 0.021). Conclusion: CDS was applied to patients who suffered from psycho-existential suffering, which often associated with desire or request for a hastened death. Further studies and debate are warranted to develop feasible treatment strategies for psycho-existential suffering.

Palliative Care in Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease of the motor neurons. Given the evolutive characteristics of this disease, palliative care principles should be a foundation of ALS care. A multidisciplinary medical intervention is of paramount importance in the different phases of disease. The involvement of the palliative care team improves quality of life and symptoms, and prognosis. Early initiation is of paramount importance to ensuring patient-centered care, when the patient has still the capability to communicate effectively and participate in his medical care. Advance care planning supports patients and family members in understanding and sharing their preferences according to their personal values and life goals regarding future medical treatment. The principal problems which require intensive supportive care include cognitive disturbances, psychological distress, pain, sialorrhrea, nutrition, and ventilatory support. Communication skills of health-care professionals are mandatory to manage the inevitability of death. Palliative sedation has peculiar aspects in this population, particularly with the decision of withdrawing ventilatory support.

Palliative sedation therapy for terminal movement disorders

Palliative sedation therapy (PST) can be a challenging area of palliative medicine because of the complex ethical considerations involved. PST is a medical therapy used for refractory symptoms in terminally ill patients and is often considered ethically justified due to the principle of double effect. Even in cases where PST is clearly indicated such as refractory cancer pain, there is potential for moral distress among clinicians. Here, we present a unique case in which multiple therapeutic options were limited in a patient with overlapping diagnoses of catatonia, medication-induced extrapyramidal symptoms, and dementia with Lewy bodies. We review how existing frameworks can be applied to similar situations and offer practical strategies to support medical decision-making regarding PST and reduce the risk of moral distress among clinicians.

Expert-approved best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care (SedPall)

BACKGROUND

The use of sedative drugs and intentional sedation in end-of-life care is associated with clinical, ethical and legal challenges. In view of these and of the issue's great importance to patients undergoing intolerable suffering, we conducted a project titled SedPall ("From anxiolysis to deep continuous sedation - Development of recommendations for sedation in palliative care") with the purpose of developing best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care and obtaining feedback and approval from experts in this area.

DESIGN

Our stepwise approach entailed drafting the recommendations, obtaining expert feedback, conducting a single-round Delphi study, and convening a consensus conference. As an interdisciplinary group, we created a set of best practice recommendations based on previously published guidance and empirical and normative analysis, and drawing on feedback from experts, including patient representatives and of public involvement participants. We set the required agreement rate for approval at the single-round Delphi and the consensus conference at ≥80%.

RESULTS

Ten experts commented on the recommendations' first draft. The Delphi panel comprised 50 experts and patient and public involvement participants, while 46 participants attended the consensus conference. In total, the participants in these stages of the process approved 66 recommendations, covering the topics "indications", "intent/purpose [of sedation]", "decision-making", "information and consent", "medication and type of sedation", "monitoring", "management of fluids and nutrition", "continuing other measures", "support for relatives", and "team support". The recommendations include suggestions on terminology and comments on legal issues.

CONCLUSION

Further research will be required for evaluating the feasibility of the recommendations' implementation and their effectiveness. The recommendations and the suggested terminology may serve as a resource for healthcare professionals in Germany on the use of sedative drugs and intentional sedation in specialist palliative care and may contribute to discussion on the topic at an international level.

TRIAL REGISTRATION

DRKS00015047 (German Clinical Trials Register).

Palliative sedation: autonomy, suffering, and euthanasia

PURPOSE OF REVIEW

This contemporary and novel review of palliative sedation explores some of the distinctive ethical problems associated with that intervention. It is timely in light of recent reviews of palliative care guidelines on the topic and given the current public debates around the related but distinct practice of euthanasia.

RECENT FINDINGS

The main themes discussed are patient autonomy, the nature of suffering and how to alleviate it, and the relationship between palliative sedation and euthanasia.

SUMMARY

First, palliative sedation poses a significant problem for patient autonomy, both in terms of securing informed consent and in terms of the ongoing effect on individual well-being. Second, as an intervention to alleviate suffering, it is appropriate only in limited cases and counterproductive in others, for example, where an individual values their ongoing psychological or social agency more than the relief of pain or negative experience. Third, people's ethical views about palliative sedation are often coloured by their understanding of the legal and moral status of assisted dying and euthanasia; this is unhelpful and occludes the interesting and urgent ethical questions raised by palliative sedation as a distinct end-of-life intervention.

Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates

Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.

Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey

BACKGROUND

Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs).

AIM

The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting.

DESIGN AND SETTING

French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies.

RESULTS

A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5-18] mg h-1) and propofol (200 [120-250] mg h -1). The Richmond Agitation Sedation Scale (RASS) was -5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices (n = 98), medicines doses were higher with no difference in the depth of sedation.

CONCLUSIONS

This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.

Palliative Extubation: A Discussion of Practices and Considerations

Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.

A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units

Background

The end-of-life (EOL) decisions continue to be debated for their moral and legal standing. The acceptance of these decisions varies, based upon the perceptions and personal choices of the intensivists.

Materials and methods

An online questionnaire-based survey was designed and circulated among the practicing intensivists via Indian Society of Critical Care Medicine (ISCCM) e-mail.

Results

Out of 200 responses, 165 (82.5%) affirmed that EOL decisions are routinely undertaken in their intensive care units. The most prevalent reasons expressed for avoidance of EOL decisions are moral and ethical dilemmas and fear of litigation. There is notable variability in the practice of withholding (47.7%) vs withdrawal (3.5%) of therapies. A good proportion of intensivists follow do-not-intubate (91%) and do-not-resuscitate (86%) orders, whereas only 18% affirmed to be practicing terminal extubation. About 93% of the respondents acknowledged the use of monitoring toward the EOL, and 49% reported the use of preformatted documents. A meager 2% admitted to facing a medicolegal issue after taking an EOL decision.

Conclusion

The survey establishes a general acceptance among the Indian intensivists regarding providing compassionate care to terminally ill patients, especially toward the EOL. The pattern of responses, however, indicates significant dilemmas and hesitancy with regard to the decision-making process.

How to cite this article

Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):531-536.

Should we all die asleep? The problem of the normalization of palliative sedation

Palliative sedation is a medical intervention to manage distress in dying patients, by reducing consciousness when symptom-directed therapies fail. Continuous deep sedation is ethically sensitive because it may shorten life and completely prevents communication. But sedation short of this is also common. There has been a steady increase in the use of sedation over recent decades. Sedation may have become a means to die while sleeping, rather than a method of last resort to alleviate suffering. Sedation may be requested or expected by patients, families or staff. The need for sedation may be being interpreted more loosely. The acceptance of a 'tolerable amount of discomfort' may have lost ground to a desire to get the final phase over with quickly. Sedation is not always a bad thing. Medical care is otherwise unable to completely control all distressing symptoms in every patient. Sedation may result from other necessary symptom control drugs. Dying when sedated can be seen by as 'peaceful'. We feel it is necessary, however, to highlight three caveats: the need to manage expectations, the cost in terms of loss of communication, and the grey area between continuous deep sedation and euthanasia. We conclude that there may be good grounds for sedation in palliative care, and in some cases, continuous deep sedation may be used as a last resort. But the criteria of necessary and proportionate drug treatment should remain. The normalisation of sedation into dying while sleeping should be resisted.

Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology

BACKGROUND

In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception.

METHODS

Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter.

RESULTS

63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life.

CONCLUSION

Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.

Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach

Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.

Use of palliative sedation following Medical Assistance in Dying (MAiD) legislation: A mixed-methods study of palliative care providers

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.

Ethical considerations in the relief of cancer pain

The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.

Pharmacists are initiators in palliative care for patients with rare diseases

The World Health Organization supports early delivery of palliative care as it reduces unnecessary hospital admissions and the inappropriate use of health care services. A community pharmacist can play a key role in advocating timely access to palliative care. Medication reconciliation must alert them to start communicating with the patient and/or his relatives about refocusing treatment and care as part of palliative and terminal care. Pharmaceutical activities for these patients include dispensing of devices and medicinal products, compounding personalized medication and participating as a member of the Palliative Support Team. Most of the several thousands of rare diseases are caused by genetic defects and up to now have no cure and a late diagnosis.

Continuous palliative sedation in terminally ill patients with cancer: a retrospective observational cohort study from a Chinese palliative care unit

OBJECTIVE

This study aimed to describe a 4-year practice of continuous palliative sedation (CPS) in a palliative medicine ward of an academic hospital in China. To compare the survival time of patients with cancer with and without CPS during end-of-life care, we used the propensity score matching method and explored potential patient-related factors.

DESIGN

A retrospective observational cohort study.

SETTING

The palliative ward at a tertiary teaching hospital between January 2018 and 10 May 2022, in Chengdu, Sichuan, China.

PARTICIPANTS

The palliative care unit had 1445 deaths. We excluded 283 patients who were sedated on admission due to mechanical ventilation or non-invasive ventilators, 122 patients who were sedated due to epilepsy and sleep disorders, 69 patients without cancer, 26 patients who were younger than 18 years, 435 patients with end-of-life intervention when the patients' vital signs were unstable and 5 patients with unavailable medical records. Finally, we included 505 patients with cancer who met our requirements.

MAIN OUTCOME MEASURES

The survival time and analysis of sedation potential factors between the two groups were compared.

RESULTS

The total prevalence of CPS was 39.7%. Patients who were sedated more commonly experienced delirium, dyspnoea, refractory existential or psychological distress, and pain. After propensity score matching, the median survival was 10 (IQR: 5-17.75) and 9 days (IQR: 4-16) with and without CPS, respectively. After matching, the two survival curves of the sedated and non-sedated groups were no different (HR 0.82; 95% CI 0.64 to 0.84; log-rank p=0.10).

CONCLUSIONS

Developing countries also practise palliative sedation. Median survival was not different between patients who were and were not sedated.

Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study

OBJECTIVE

Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan.

METHODS

Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries.

RESULTS

A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001).

CONCLUSIONS

Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.

Palliative care and new technologies. The use of smart sensor technologies and its impact on the Total Care principle

BACKGROUND

Palliative care is an integral part of health care, which in term has become increasingly technologized in recent decades. Lately, innovative smart sensors combined with artificial intelligence promise better diagnosis and treatment. But to date, it is unclear: how are palliative care concepts and their underlying assumptions about humans challenged by smart sensor technologies (SST) and how can care benefit from SST?

AIMS

The paper aims to identify changes and challenges in palliative care due to the use of SST. In addition, normative guiding criteria for the use of SST are developed.

METHODS

The principle of Total Care used by the European Association for Palliative Care (EAPC) forms the basis for the ethical analysis. Drawing on this, its underlying conceptions of the human and its socio-ethical aspects are examined with a phenomenological focus. In the second step, the advantages, limitations, and socio-ethical challenges of using SST with respect to the Total Care principle are explored. Finally, ethical-normative requirements for the application of SST are derived.

RESULTS AND CONCLUSION

First, SST are limited in their measurement capabilities. Second, SST have an impact on human agency and autonomy. This concerns both the patient and the caregiver. Third, some aspects of the Total Care principle are likely to be marginalized due to the use of SST. The paper formulates normative requirements for using SST to serve human flourishing. It unfolds three criteria according to which SST must be aligned: (1) evidence and purposefulness, (2) autonomy, and (3) Total Care.

Sedation in Palliative Care—a Clinically Oriented Overview of Guidelines and Treatment Recommendations

BACKGROUND

The appropriate provision of sedation as a last resort for the relief of suffering in palliative care is dealt with variably in actual practice. This article is intended as an overview of practically relevant information found in treatment recommendations and guidelines.

METHODS

A systematic literature search was conducted in the PubMed, Scopus, and Google Scholar databases, and a manual search was carried out online. Recommendations that were not available in either German or English, or that were specific to pediatric practice, were excluded. Publication quality was assessed with the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II). The recommendations in the documents were qualitatively evaluated.

RESULTS

29 publications (11 journal articles, 18 other) of varying quality according to AGREE II were included. All recommendations and guidelines were essentially based on expert consensus. The common indications for sedation are otherwise intractable delirium, dyspnea, and pain, in patients with a life expectancy of no more than two weeks. Existential distress is a controversial indication. The drug of first choice is midazolam. As the sedating effect of opioids is hard to predict, they should not be used as sedatives. The risks of sedation include respiratory and circulatory depression, as well as the loss of communicative ability, control, and autonomy. It is generally recommended that the patient's symptom burden and depth of sedation should be monitored; clinical and technically supported monitoring are recommended in some publications as well, depending on the situation.

CONCLUSION

There is a broad consensus in favor of sedation to relieve suffering in the last days and hours of life. Recommendations vary for patients with a longer life expectancy and for those with existential distress, and with respect to monitoring.

The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review

BACKGROUND

Clinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients' situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS.

OBJECTIVES

To describe the clinical practice of PS in patients with COVID versus non-COVID patients.

METHODS

A retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March '20 and January '21 were included.

RESULTS

During the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08).

CONCLUSION

PS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.

Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams

CONTEXT

Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families.

OBJECTIVES

Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016.

METHODS

We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019.

RESULTS

Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction.

CONCLUSION

Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.

Response to "The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey''

We have several major concerns about this article [Guastella et al 2021]. Although it states that it is about palliative sedation, it is not. Rather, it is about the French Claeys Leonetti Law about Continuous Deep Sedation (CDS) at the end of life [Loi n°2016-87].

Implementation of clinical guidelines in specialized palliative care-results from a national improvement project: A national register-based study

BACKGROUND

Knowledge about the process and the results of the implementation of clinical guidelines to improve palliative care is limited. A national project aimed at improving the quality of life of advanced cancer patients admitted to specialized palliative care services in Denmark by implementing clinical guidelines for the treatment of pain, dyspnea, constipation, and depression.

AIM

To investigate the degree of clinical guideline implementation by evaluating the proportion of patients treated according to guidelines among those who qualified (i.e. reported severe symptom level) before and after the 44 palliative care services implemented the guidelines, and how often different types of interventions were provided.

DESIGN

This is a national register-based study.

SETTING/PARTICIPANTS

Data from the improvement project were stored in and later obtained from the Danish Palliative Care Database. Adult patients with advanced cancer admitted to palliative care between September 2017 and June 2019 who answered the EORTC QLQ-C15-PAL questionnaire were included.

RESULTS

In total 11,330 patients answered the EORTC QLQ-C15-PAL. The proportions of services that implemented the four guidelines ranged 73%-93%. Among services that had implemented guidelines, the proportion of patients receiving interventions was roughly constant over time reaching between 54% and 86% (lowest for depression). Pain and constipation were frequently treated pharmacologically (66%-72%), whereas dyspnea and depression were frequently treated non-pharmacologically (61% each).

CONCLUSIONS

Implementing clinical guidelines was more successful for physical symptoms than for depression. The project generated national data on interventions provided when guidelines were followed, which may be used to understand differences in care and outcomes.

[Pain management in German specialized outpatient palliative care : A cross-sectional study to present the current pain management of palliative patients in the home environment]

BACKGROUND

With the help of specialized outpatient palliative care teams (German abbreviation: SAPV), seriously ill and dying patients in Germany can be adequately cared for in their home environment until the end of their lives; however, there are no uniform standards or guidelines for well-executed pain management right now.

OBJECTIVE

This approach serves as basic research in the field of public health research. This is intended to present which methods (use of different professional groups, use of pain medications, alternative medical treatment etc.) the individual SAPV teams use for pain management. From this it can be deduced which procedures can be considered particularly effective.

MATERIAL AND METHODS

This cross-sectional study was conducted in May 2021. All German SAPV teams (n = 307) listed on the homepage of the German Association for Palliative Medicine (DGP) were contacted by post and invited to participate. A total of 175 teams (57%) responded to the request and were included in the evaluation. A descriptive data analysis was performed.

RESULTS

Pain management in the German outpatient care of palliative patients is based on several components. All common pain medications are used, but primarily metamizole (99.4%) as a non-opioid analgesic, morphine (98.3%) from the opiate series and pregabalin (96.6%) as a co-analgesic are mainly prescribed. If pain therapy fails, 22.5% of the SAPV teams perform palliative sedation for symptom control on a regular basis.

CONCLUSION

This cross-sectional study is the first of its kind to provide a general overview of the treatment options for pain management in German outpatient palliative care. In comparison with international studies, the question arises as to whether uniform therapy schemes and a reduction in the medication available in the individual SAPV teams could lead to an improvement in patient care.