Palliative sedation: The end of heated debate?

Experiences and perceptions of continuous deep sedation: An interview study among Dutch patients and relatives

BACKGROUND

The incidence of continuous deep sedation (CDS) has more than doubled over the last decade in The Netherlands, while reasons for this increase are not fully understood. Patients and relatives have an essential role in deciding on CDS. We hypothesize that the increase in CDS practice is related to the changing role of patients and relatives in deciding on CDS.

OBJECTIVE

To describe perceptions and experiences of patients and relatives with regard to CDS. This insight may help professionals and policymakers to better understand and respond to the evolving practice of CDS.

METHODS

Qualitative interviews were held with patients and relatives who had either personal experience with CDS as a relative or had contemplated CDS for themselves.

RESULTS

The vast majority of respondents appreciated CDS as a palliative care option, and none of the respondents reported (moral) objections to CDS. The majority of respondents prioritized avoiding suffering at the end of life. The patients and families generally considered CDS a palliative care option for which they can choose. Likewise, according to our respondents, the decision to start CDS was made by them, instead of the physician. Negative experiences with CDS care were mostly related to loss of sense of agency, due to insufficient communication or information provision by healthcare professionals. Lack of continuity of care was also a source of distress. We observed a variety in the respondents' understanding of the distinction between CDS and other end-of-life care decisions, including euthanasia. Some perceived CDS as hastening death.

CONCLUSION

The traditional view of CDS as a last resort option for a physician to relieve a patient's suffering at the end of life is not explicit among patients and relatives. Instead, our results show that they perceive CDS as a regular palliative care option. Along with this normalization of CDS, patients and relatives claim a substantial say in the decision-making and are mainly motivated by a wish to avoid suffering and exercise control at the end of life. These distinct views on CDS of patients, their relatives and healthcare providers should be reconciled in guidelines and protocols for CDS.

PATIENT OR PUBLIC CONTRIBUTION

One of the authors in our team (G. H.) has experience with CDS as a relative and ensured that the patient/relative viewpoint was adequately reflected in the design and conduct of our study. In the preliminary phase of our study, G. H. adjusted the topic list so it was better adapted to the current practice of CDS. During the data analysis, G. H. read several interviews and took part in the open and critical discussion on central themes and core concepts as an important member of the author team, thereby guaranteeing the central position of the patient/relative perspective in our final research outcome.

Continuous deep sedation at the end of life: a qualitative interview-study among health care providers on an evolving practice

BACKGROUND

Continuous deep sedation (CDS) can be used for patients at the end of life who suffer intolerably from severe symptoms that cannot be relieved otherwise. In the Netherlands, the use of CDS is guided by an national guideline since 2005. The percentage of patients for whom CDS is used increased from 8% of all patients who died in 2005 to 18% in 2015. The aim of this study is to explore potential causes of the rise in the use of CDS in the Netherlands according to health care providers who have been participating in this practice.

METHODS

Semi-structured interviews were conducted and thematically analysed. Participants were Dutch health care providers (HCPs), working at patients' homes, hospices, elderly care facilities and in hospitals and experienced in providing CDS, who were recruited via purposeful sampling.

RESULTS

41 Health care providers participated in an interview. For these HCPs the reason to start CDS is often a combination of symptoms resulting in a refractory state. HCPs indicated that symptoms of non-physical origin are increasingly important in the decision to start CDS. Most HCPs felt that suffering at the end of life is less tolerated by patients, their relatives, and sometimes by HCPs; they report more requests to relieve suffering by using CDS. Some HCPs in our study have experienced increasing pressure to perform CDS. Some HCPs stated that they more often used intermittent sedation, sometimes resulting in CDS.

CONCLUSIONS

This study provides insight into how participating HCPs perceive that their practice of CDS changed over time. The combination of a broader interpretation of refractory suffering by HCPs and a decreased tolerance of suffering at the end of life by patients, their relatives and HCPs, may have led to a lower threshold to start CDS.

TRIAL REGISTRATION

The Research Ethics Committee of University Medical Center Utrecht assessed that the study was exempt from ethical review according to Dutch law (Protocol number 19-435/C).

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.

"It's pretty much flying blind in the home care setting": A qualitative study on the influence of home care specific circumstances on sedation in specialist palliative home care

BACKGROUND

Existing data on sedation at the end of life indicate challenges in the home care setting, leading to deviations from guidelines or non-provision of sedation.

AIM

As part of the "SedPall" study, we aimed to explore circumstances in specialist palliative home care, which influence the practice of sedation.

DESIGN

Semi-structured qualitative interviews (n = 59) and two focus groups (n = 4, n = 5). Recruitment took place via contact persons. We thematically analyzed the transcripts with the Framework Approach, using MAXQDA 2018.2.

SETTING/PARTICIPANTS

Physicians, nurses, and other members of the multiprofessional team from 10 palliative care units and seven home care teams.

RESULTS

Participants reported home care specific circumstances that can be categorized into three interrelated topics. (1) Lack of 24/7 on-site availability, (2) active involvement of the family, (3) challenges regarding teamwork and multidisciplinarity. Participants drew different conclusions from the reported circumstances regarding the feasibility of different types of sedation at home: While some reported to generally use all types of sedation, others stated that some types of sedation are not feasible in home care, for example deep sedation until death. Most participants questioned the applicability of existing sedation guidelines in the home care setting.

CONCLUSION

Our data indicate that sedation practices might currently follow the healthcare professional's attitude or service policy rather than the patient's need. To avoid hospital admission in manageable cases and ensure that home care specific best practice standards are met, existing guideline recommendations have to be adapted and supplemented by additional supporting measures specific for the home care setting.

Sedatives and Sedation at the End of Life in the Hospital

BACKGROUND

Data on sedation at the end of life (eol) in different medical disciplines are scarce and mostly based on subjective reports. We aimed to assess the use of sedatives with continuous effect in the last week of life and associated factors in different hospital departments, with the aid of objectifiable criteria.

METHODS

We conducted a retrospective cohort study based on the medical records of patients who died in one of five clinical departments of German hospitals between January 2015 and December 2017 (hematology/oncology [two different departments], neurology, geriatrics, and gynecology). The use of sedatives that are recommended in guidelines for palliative sedation was analyzed, irrespective of indication and treatment intent, with the aid of published definitions of continuous effect and of at least moderately sedating doses. The analysis consisted of descriptive statistics and multivariate logistic regression analysis.

RESULTS

260/517 (50%) of the patients who died were given sedatives with continuous effect in the last week of life, 53/517 (10%) in at least moderately sedating doses. For 76/260 (29%) patients, no indication was noted. The term "sedation" was used in the medical records of 20/260 (8%) patients. The use of sedatives with continuous effect was significantly associated with the department in which the patient was treated (hematology/oncology II: OR 0.32, 95% CI [0.16: 0.63]; geriatrics: OR 0.23, 95% CI [0.10:0.50]; reference, hematology/oncology I).

CONCLUSION

It was not possible to draw a clear distinction between the use of sedatives for symptom control, without sedating effect or intent to sedate, and intentional sedation to relieve suffering. The observed differences between hospital departments and deviations from recommended practice, e.g. lack of documentation of the indication, warrant further exploration. Moreover, context-specific supportive measures for the use of sedatives and sedation at the end of life should be developed.

The debate about physician assisted suicide and euthanasia in Ireland - Implications for psychiatry

At present, Physician-Assisted Suicide and Euthanasia are illegal in Ireland, and are forbidden under the Irish Medical Council's ethical guidelines. With the recent introduction of a Bill in the Irish Dáil (Parliament) which would have permitted Physicial-Assisted Suicide in that country, Physician-Assisted Suicide and Euthanasia (PAS-E) has become the subject of debate, both within the medical profession and in the wider community. Geographical and historical considerations mean that the Irish situation may have relevance to many other countries, which have apparently little similarity among themselves. PAS-E is becoming more widespread and more acceptable in many countries throughout the world. There are ramifications for many aspects of medical care, and matters such as the broadening of euthanasia criteria beyond terminal illness, attitudes toward suicide, and the determination of capacity and voluntariness, suggest that it will be an important issue, not only for psychiatrists, but for the wider medical community as well, in the coming years.

Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It

CONTEXT

The French parliament passed a groundbreaking law in 2016, opening a right for patients to access continuous and deep sedation until death (CDS) at the end of life, under conditions. Parliamentarians' goal was to consolidate patients' rights whilst avoiding legislating on medical aid in dying.

OBJECTIVES

To conduct a first national retrospective survey on CDS to evaluate the number of CDS requested, proposed and performed in 2017 and to elicit qualitative data from physicians on the practice and on the terms used by patients to refer to CDS.

METHODS

Early 2018, an online survey was sent to all French hospitals, nursing homes, hospital at homes services and general practitioners (GPs). Descriptive statistics and qualitative inductive content analysis were used to analyze the data and comments of respondents.

RESULTS

The qualitative data show that respondents generally approve the law on CDS as it sets a legal framework; nonetheless, there is a persistent controversy about CDS vs. euthanasia for some physicians in all settings. GPs reported limited access to midazolam and the difficulty in organizing multidisciplinary procedures as major constraints. In hospital settings in particular, differentiating CDS from other sedation practices is uneasy. All physicians reported patients use multiple elements of language to request CDS.

CONCLUSION

After the law was passed in France, CDS were requested, proposed and performed in all medical settings, in nursing homes, at home. The qualitative data presented here show the relevance of exploring physicians' reflexive stances on this practice in different settings and within the context of a patient-physician relationship marked by a new patient's right. The study highlights the wide range of elements of language used by patients at the end of life, as understood by respondent physicians to mean a request for CDS and underscores the polymorphous meaning of CDS.

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’.

Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes

BACKGROUND AND OBJECTIVES

While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved.

RESEARCH DESIGN AND METHODS

Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach.

RESULTS

Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available.

DISCUSSION AND IMPLICATIONS

The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.

Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature

CONTEXT

The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients.

OBJECTIVE

To gain insight in developments in the use of CSD in various countries and subpopulations.

METHODS

We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death.

RESULTS

We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families.

CONCLUSIONS

The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.

What do you mean by "palliative sedation"? : Pre-explicative analyses as preliminary steps towards better definitions

BACKGROUND

Sedation in palliative care is frequently but controversially discussed. Heterogeneous definitions and conceptual confusion have been cited as contributing to different problems 1) relevant to empirical research, for example, inconsistent data about practice, the 'data problem', and 2) relevant for an ethically legitimate characterisation of the practice, the 'problem of ethical pre-emption'. However, little is known about how exactly definitions differ, how they cause confusion and how this can be overcome.

METHOD

Pre-explicative analyses: (A) systematic literature search for guidelines on sedation in palliative care and systematic decomposition of the definitions of the practice in these guidelines; (B) logical distinction of different ways through which the two problems reported might be caused by definitions; and (C) analysis of how content of the definitions contributes to the problems reported in these different ways.

RESULTS

29 guidelines from 14 countries were identified. Definitions differ significantly in both structure and content. We identified three ways in which definitions can cause the 'data problem' - 1) different definitions, 2) deviating implicit concepts, 3) disagreement about facts. We identified two ways to cause the problem of ethical pre-emption: 1) explicit or 2) implicit normativity. Decomposition of definitions linked to the distinguished ways of causing the conceptual problems shows how exactly single parts of definitions can cause the problems identified.

CONCLUSION

Current challenges concerning empirical research on sedation in palliative care can be remediated partly by improved definitions in the future, if content and structure of the used definitions is chosen systematically. In addition, future research should bear in mind that there are distinct purposes of definitions. Regarding the 'data problem', improving definitions is possible in terms of supplementary information, checking for implicit understanding, systematic choice of definitional elements. 'Ethical pre-emption', in contrast, is a pseudo problem if definitions and the relationship of definitions and norms of good practice are understood correctly.

Ethics of crisis sedation: questions of performance and consent

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term 'crisis sedation.' We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.

Using sedative substances until death: A mortality follow-back study on the role of healthcare settings

Background:

In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated.

Aim:

To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control.

Design:

National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older.

Setting/participants:

Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included.

Results:

Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001).

Conclusion:

In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.

Palliative Sedation for the Terminally Ill Patient

Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.