Ethical challenges in palliative sedation of adults: protocol for a systematic review of current clinical practice guidelines

INTRODUCTION

This study aims to identify the full spectrum of ethical challenges of all forms of palliative sedation for adults as presented in current clinical practice guidelines (CPGs) and to determine whether CPGs specify ethical challenges of this therapy for patients with cancer and non-cancer and, if so, how exactly they do this. To the best of our knowledge, no studies have yet investigated this topic. The purpose is purely descriptive; our aim is not to make any kind of normative judgements on these challenges. Nor is our aim to assess the quality of the CPGs.

METHODS AND ANALYSIS

We will perform a systematic review of CPGs on palliative sedation for adults via five electronic databases, grey literature search tools, citation tracking and contact with palliative care experts. Current CPGs accredited by an international, national or regional authority, published in English, German, French, Italian or Polish, from 2000 to the date of the search, will be subjected to content analysis at the textual, linguistic and thematic levels.

ETHICS AND DISSEMINATION

This is a protocol for a systematic review and no human will be involved in this research. Therefore, ethics approval and consent to participate are not applicable to this context. This study protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis for Protocols criteria and registered on PROSPERO. Moreover, the integral version of this study protocol is published as a preprint on Research Square. The results of this study will be actively disseminated through peer-reviewed journals and books, international, national and local conference presentations, social media and media in general.

The conscious state of the dying patient: An integrative review

OBJECTIVES

The cognitive state of the dying in the last days of life may deteriorate, resulting in a reduced ability to communicate their care needs. Distressing symptoms, physical and existential, may go unrecognized and untreated. The objectives of this integrative review were to systematically interrogate the literature to determine the changing conscious state of dying adults and to identify changes in their care needs.

METHODS

An integrative review protocol was registered with PROSPERO (CRD42020160475). The World Health Organization definition of palliative care informed the review. CINAHL, MEDLINE (OVID), Scopus, PsycINFO, Cochrane Library, and PubMed were searched from inception to October 2019 using search strategies for each database. Inclusion and exclusion criteria were applied. Methodological quality was appraised using the Joanna Briggs Institute Checklist for the Case Series appraisal tool. Extracted data were synthesized using a narrative approach.

RESULTS

Of 5,136 papers identified, 11 quantitative case series studies were included. Six themes were identified: conscious state and change over time, awareness, pain, absence of holistic care, the voiceless patient, and signs and symptoms of dying.

SIGNIFICANCE OF RESULTS

In the last days of life, the physical and conscious state of the dying patient declines, resulting in an inability to express their care needs. Dignity in dying and freedom from pain and suffering are both an imperative and a human right; and unvoiced care needs can result in unnecessary suffering and distress. This review revealed that little is known about how healthcare professionals assess holistic care needs at this vulnerable time. Although much has been written about palliative and end-of-life care, the assessment of care needs when patients are no longer able to voice their own needs has largely been ignored, with little attention from clinical, educational, or research perspectives. This gap in evidence has important implications for the dying and their families.

The Health Care Providers' Perspectives on End-of-Life Patients' Sense of Dignity. A Comparison Among Four Different Professionals' Categories

The studies on terminally ill patients' dignity as perceived by health care providers (HCPs) in palliative care are growing. The comparison of different HCPs' perspectives in particular is necessary to explore how HCPs perceive patients' dignity in order to promote reflection on this core issue. This study aimed to investigate the perspectives on end-of-life patients' sense of dignity among four different categories of professionals: nurse assistants, nurses, psychologists, and physicians. A sample of 306 HCPs completed the Patient Dignity Inventory-Italian Version (PDI-IT) adapted for them and an ad hoc semi-structured written interview. Their responses were then analyzed using frequencies of the answers to the PDI-IT, a multivariate analysis of variance, Pearson's correlation index, t tests, and content analysis. All HCPs scored the relevance to the dignity-related physical aspects highly, followed by the psychological distress. Nurse assistants and nurses provided higher scores on the psychological and existential and spiritual PDI subscales than the other HCP groups. The social sphere was evaluated as the least salient for the patients' sense of dignity. Physicians who attended a course on dignity considered the psychological and existential dignity dimensions more. Differences in role and expertise could lead to different HCPs' perspectives on dignity, while the multidisciplinary work could favor their aligning. Therefore, it is essential to encourage HCPs' communicative exchange and reflective awareness through training, i.e., courses, seminars, and focus groups. These developments could promote increasingly adequate patient-centered care.

Characterisation of palliative sedation use in inpatients at a medium-stay palliative care unit

Background

Palliative sedation has been used to refer to the practice of providing symptom control through the administration of sedative drugs. The objective of this article was to characterise palliative sedation use in inpatients at a medium-stay palliative care unit.

Material and methods

A cross-sectional study was conducted on 125 randomly selected patients (aged 15 or older) who had died in 2014. The Palliative Performance Scale was used to evaluate the functional status.

Results

Palliative sedation was documented in 34.4% of the patients and midazolam was the most commonly used sedative agent (86.0%). More than half (53.5%) of those who recieved sedation presented with delirium. Liver dysfunction was more frequent in the sedated patients (p=0.033) and patients with heart disease were less likely (p=0.026) to be sedated.

Conclusion

Palliative sedation is an ethically accepted practice. It was commonly midazolam-induced, and differences were documented, among sedated and non-sedated patients, in terms of liver dysfunction and heart disease.

Meeting Existential Needs in Palliative Care—Who, When, and Why?

Existential concerns are of great importance to those who are terminally ill. However, these matters are seldom brought into focus in the care of the patients. One crucial question is: who should take care of the patient's existential needs? The present study focuses on possible alternatives for dealing with such concerns, including the staff or significant others. A focus group was set up to gather and examine reflections from people having first-hand experience with this problem. The results of this study indicate that, with regard to existential needs, there are no general solutions. On the other hand, under specific conditions, several solutions can be satisfactory. Possible ways of handling the problem are suggested. Moreover, staff should pay attention to constraints operating in care settings, such as continuity and time, competent organization, and personal prerequisites.

Patient Dignity Inventory (PDI) Questionnaire: The Validation Study in Italian Patients with Solid and Hematological Cancers on Active Oncological Treatments

Backgrounds

In Oncology, little is known about dignity-related distress and the issues that influence the sense of dignity for patients. We validated the Patient Dignity Inventory (PDI) questionnaire in Italian patients on oncological active treatments.

Methods

After the translation procedures, the PDI was administered to 266 patients along with other questionnaires to assess the psychometric properties of the Italian version of PDI. Factor structure was tested by both explorative and confirmatory factor analyses. Concurrent validity was tested through convergent and divergent validity with validated questionnaires inquiring about physical and psychological symptoms, and religiosity. The test/retest reliability was assessed through the concordance coefficient of Linn (two-week interval, 80 patients).

Results

The explorative analysis suggested one factor only loading highly on all the 25 items (>.45) and explaining the 48% variance; confirmative analysis and Cronbach alpha (0.96) confirmed the adequacy of the one-factor model. In the 2-week test-retest study, a concordance coefficient of 0.73 (95% CI, 0.64–0.83) was found. High correlations of problems with dignity were found with both physical and psychological symptoms (0.52 and 0.64 rho coefficient, respectively), and a moderate inverse correlation with spiritual well being (-.40). The dignity construct, as measured by PDI, proved to be orthogonal to that of religiosity (-.02).

Conclusions

The Italian version of PDI is a valid and reliable tool to evaluate the dignity related-distress in out-patients with solid and hematological cancers, on active oncological treatments, in non advanced stages of the disease.

To explore the relationship between the use of midazolam and cessation of oral intake in the terminal phase of hospice inpatients: A retrospective case note review: Does midazolam affect oral intake in the dying?

BACKGROUND

Sedative drugs are used to improve comfort in dying patients but have been accused of shortening survival by reducing patients' ability to maintain nutrition and hydration. However, as part of the dying process, patients in the last days of life often have impaired conscious levels and an inability to maintain oral intake.

AIM

To establish whether the decline in oral intake is related to the use of midazolam in the last week of life.

DESIGN

This is a retrospective case note review.

SETTING/PARTICIPANTS

The data were obtained from nursing records and medication charts of 125 consecutive hospice inpatients who died at a hospice in South London.

RESULTS

A total of 72 patients received midazolam on one or more days within the last 7 days of life (midazolam group) and 49 patients received no midazolam (control group).

CONCLUSION

Mean oral intake was reduced 7 days prior to death and declined sequentially over subsequent days in both patient groups. More patients required midazolam as death approached and most patients received midazolam for less than 3 days. Mean doses of midazolam used were low. Patients in the midazolam group had lower oral intake than those in the control group, but this association does not indicate causation.

Dying with dignity: The good patient versus the good death

Death is a unique experience for each human being, yet there is tremendous societal pressure on a dying person to be a “good patient” while trying to experience the “good death.” These pressures shape patient, caregiver, and family choices in end-of-life situations.

The purpose of this literature review was twofold: first, to develop an understanding of “dying with dignity” to enhance the end-of-life care received by dying patients, and second, to contribute to a concept analysis of dignity to improve the clarity and consistency of future research related to dignity in aging individuals. Articles pertaining to dying with dignity from the disciplines of nursing, medicine, ethics, psychology, and sociology were reviewed using a matrix method. 1

A dichotomy surrounding dying with dignity emerged from this review. The definition of dignity in dying identifies not only an intrinsic, unconditional quality of human worth, but also the external qualities of physical comfort, autonomy, meaningfulness, usefulness, preparedness, and interpersonal connection. For many elderly individuals, death is a process, rather than a moment in time, resting on a need for balance between the technology of science and the transcendence of spirituality.

A new measure of home care patients' dignity at the end of life: The Palliative Patients' Dignity Scale (PPDS)

Objective:

This study aimed to develop a new and brief instrument to be employed in dignity measurement, one based on the perceptions of patients, relatives, and professionals about dignity.

Method:

Surveys of patients receiving palliative care, family caregivers, and palliative care professionals were first carried out (sample 1). In the second step, palliative care patients were surveyed with a pilot questionnaire (sample 2). Finally, a survey design was used to assess patients admitted into a home care unit (sample 3). Sample 1 included 78 subjects, including patients, family caregivers, and professionals. Some 20 additional palliative patients participated in sample 2. Finally, 70 more patients admitted to a home care unit participated were surveyed (sample 3). Together with the Palliative Patients' Dignity Scale (PPDS), our survey included other measures of dignity, anxiety, depression, resilient coping, quality of life, spirituality, and social support.

Results:

After analyzing data from steps 1 and 2, an eight-item questionnaire was presented for validation. The new scale showed appropriate factorial validity (χ2(19) = 21.43, p = 0.31, CFI = 0.99, GFI = 0.92, SRMR = 0.07, and RMSEA = 0.04), reliability (internal consistency estimations of 0.75 and higher), criterial validity (significant correlations with the hypothesized related variables), and a cutoff criteria of 50 on the overall scale.

Significance of Results:

The new PPDS has appropriate psychometric properties that, together with its briefness, encourages its applicability for dignity assessment at the end of life.

Palliative sedation for terminally ill cancer patients in a tertiary cancer center in Shanghai, China

Background

There are a number of studies dedicated to characteristics of sedation, but these studies are mostly bound to western country practices. The aim of this study is to describe the characteristics of patients who suffered from cancer and who had been sedated until their death in Shanghai, China.

Methods

Retrospective medical data of 244 terminally ill cancer patients including 82 sedated patients were collected. Data collected included demographic characteristics, disease-related characteristics and details of the sedation.

Results

In sedated cases, patients and/or caregivers gave the consent to start palliative sedation due to unmanageable symptoms. On average, sedation was performed 24.65(±1.78)hours before death. Agitated delirium and dyspnea were the most frequent indications for palliative sedation. There was no significant difference in survival time from admission till death between sedated and non-sedated patients (p > 0.05).

Conclusions

Palliative sedation is effective for reducing terminally ill cancer patients’ suffering without hastening death. Prospective research is needed to determine the optimal conditions for Chinese patients including indications, decision making process, informed consent, cultural and ethical issues, type of sedation and drugs.

An integrative review of dignity in end-of-life care

BACKGROUND

Dying with dignity is regarded as a goal of quality end-of-life care. However, the meaning of dying with dignity is ambiguous, and no comprehensive synthesis of the existing literature has been published.

AIM

To synthesize the meaning of dying with dignity and to identify common aspects of dignity in end-of-life care.

DESIGN

This is an integrative review article. Methodological strategies specific to the integrative review method proposed by Whittemore and Knafl were followed to conduct data analysis. The matrix method was used to summarize characteristics of included articles.

DATA SOURCES

Five electronic databases were searched in October 2012, with no date restriction: PubMed, CINAHL, PsycINFO, Academic Search Premier, and Social Sciences Abstracts. Theoretical reports, and both qualitative and quantitative empirical reports, focused on dignity in end-of-life care were included.

RESULTS

Themes of dying with dignity are as follows: a human right, autonomy and independence, relieved symptom distress, respect, being human and being self, meaningful relationships, dignified treatment and care, existential satisfaction, privacy, and calm environment. Factors influencing dignity include demographic, illness-related, and treatment-/care-related factors, as well as communication. Models of dignity in end-of-life care and instruments to measure dignity were reported. Interventions to support dignity stressed physical, psychological, and spiritual supports not only to dying patients but also to family members.

CONCLUSION

This review clarified the meaning of dying with dignity and synthesized common aspects of dignity in end-of-life care. Further research is needed to evaluate the meaning of dying with dignity across cultures and to explore individualized dignity-based care.

Palliative sedation versus euthanasia: an ethical assessment

The aim of this article was to review the ethical debate concerning palliative sedation. Although recent guidelines articulate the differences between palliative sedation and euthanasia, the ethical controversies remain. The dominant view is that euthanasia and palliative sedation are morally distinct practices. However, ambiguous moral experiences and considerable practice variation call this view into question. When heterogeneous sedative practices are all labeled as palliative sedation, there is the risk that palliative sedation is expanded to include practices that are actually intended to bring about the patients' death. This troublesome expansion is fostered by an expansive use of the concept of intention such that this decisive ethical concept is no longer restricted to signify the aim in guiding the action. In this article, it is argued that intention should be used in a restricted way. The significance of intention is related to other ethical parameters to demarcate the practice of palliative sedation: terminality, refractory symptoms, proportionality, and separation from other end-of-life decisions. These additional parameters, although not without ethical and practical problems, together formulate a framework to ethically distinguish a more narrowly defined practice of palliative sedation from practices that are tantamount to euthanasia. Finally, the article raises the question as to what impact palliative sedation might have on the practice of palliative care itself. The increasing interest in palliative sedation may reemphasize characteristics of health care that initially encouraged the emergence of palliative care in the first place: the focus on therapy rather than care, the physical dimension rather than the whole person, the individual rather than the community, and the primacy of intervention rather than receptiveness and presence.

Personal dignity in the terminally ill from the perspective of caregivers: a survey among trained volunteers and physicians

BACKGROUND

Although dignity is increasingly considered a goal of palliative care, little research has evaluated the understanding of dignity at the end of life from a caregiver's perspective.

OBJECTIVE

The study objective was to investigate and compare the views of trained volunteers and SCEN physicians on maintaining dignity for patients reaching the end of life.

DESIGN

The study is a survey questionnaire study.

SUBJECTS

Subjects were two groups of caregivers involved in care for dying patients: trained volunteers (n=236) and end-of-life consultants (SCEN physicians; n=427).

MEASUREMENTS

Measurement was done via the Dutch version of the 22-item Patient Dignity Inventory on symptoms and experiences that have been shown to influence the sense of dignity in terminally ill patients. Respondents were asked to rate on a five-point scale the extent to which they considered the items as influential on dignity in terminally ill patients, and as problematic in practice in maintaining dignity for patients in the last phase of life.

RESULTS

Overall, volunteers indicated items more frequently as influential to dignity and as problematic in maintaining dignity at the end of life, compared to SCEN physicians. Volunteers gave significantly higher ratings than SCEN physicians to most of the social items, and to half of the psychological and existential items.

CONCLUSIONS

It seems that SCEN physicians consider the physical aspects of suffering to be most influential and problematic in practice in preserving dignity, while volunteers think psychosocial aspects are most important in preserving dignity at the end of life. These findings suggest that the role and responsibilities of caregivers involved in care for terminally ill patients affect the factors that they think influence dignity.

Opioid Use amongst Cancer Patients at the End of Life

Introduction: Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival. Materials and Methods: A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were collected on patients’ characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death. Results: There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the final 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69). Conclusion: Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival. Key words: Palliative care, Survival analysis, Terminal cancer

Creation and the empirical validation of the dignity card-sort tool to assess factors influencing erosion of dignity at life's end

Patients often experience erosion of dignity as they cope with the dying process. Preserving patient dignity is a sentinel premise of palliative care. This study was conducted to gain a better understanding of factors influencing erosion of dignity at the end of life. We conducted an open-ended written survey of 100 multidisciplinary providers (69% response rate) and responses were categorized to identify 18 themes that were used to create a card-sort tool. The initial 18-item tool was administered to nurses (n = 83), nonhospice community-dwelling subjects (n = 190) and hospice patients (n = 26) and a principal component analysis (PCA) was used to identify the 6 primary factors. The key item in each factor as identified by the PCA was used to create the final 6-item dignity card-sort tool (DCT). The DCT was also administered to physicians caring for palliative care patients (n = 21). For each of the final 6 items, the correlation between the respondents (nurses, physicians, nonterminally ill subjects, and subjects receiving hospice care) was calculated using the Spearman's correlation coefficient. The nurses were very highly positively correlated with the physicians (correlation coefficient = 0.94) and the community-dwelling nonterminally ill subjects were highly positively correlated with the subjects receiving hospice care (correlation coefficient = 0.67). More importantly, both the nurses and physicians were negatively correlated with both community dwelling nonterminally ill subjects and the subjects receiving hospice care. The health professionals in the study felt that treating a patient with disrespect and not carrying out their wishes resulted in erosion of dignity. In contrast patients thought that poor medical care and untreated pain were the most important factors leading to erosion of dignity at life's end. The DCT is a promising tool that may help clinicians identify key factors resulting in perceptions of erosion of dignity in adult palliative care patients.

What "best practice" could be in Palliative Care: an analysis of statements on practice and ethics expressed by the main Health Organizations

BACKGROUND

In palliative care it would be necessary to refer to a model. Nevertheless it seems that there are no official statements which state and describe that model. We carried out an analysis of the statements on practice and ethics of palliative care expressed by the main health organizations to show which dimensions of end-of-life care are taken into consideration.

METHODS

The official documents by the most representative health organisations committed to the definition of policies and guidelines for palliative and end-of-life care had been considered. The documents were analysed through a framework of the components of end-of-life care derived from literature, which was composed of 4 main "areas" and of 12 "sub-areas".

RESULTS

Overall, 34 organizations were identified, 7 international organisations, and 27 organisations operating on the national level in four different countries (Australia, Canada, UK and United States). Up to 56 documents were selected and analysed. Most of them (38) are position statements. Relevant quotations from the documents were presented by "areas" and "sub-areas". In general, the "sub-areas" of symptoms control as well as those referring to relational and social issues are more widely covered by the documents than the "sub-areas" related to "preparation" and to "existential condition". Indeed, the consistency of end-of-life choices with the patient's wishes, as well as completion and meaningfulness at the end of life is given only a minor relevance.

CONCLUSIONS

An integrated model of the best palliative care practice is generally lacking in the documents. It might be argued that the lack of a fixed and coherent model is due to the relevance of unavoidable context issues in palliative care, such as specific cultural settings, patient-centred variables, and family specificity. The implication is that palliative care staff have continuously to adapt their model of caring to the specific needs and values of each patient, more than applying a fixed, although maybe comprehensive, care model.

Palliative sedation

PURPOSE OF REVIEW

Palliative care is a discipline that provides satisfactory symptom relief to most patients with advanced life-threatening disease. There remain circumstances, however, in which patients experience distressing symptoms and unbearable suffering that cannot be adequately relieved. In these situations palliative sedation may be valuable as a last resort. Palliative sedation is a controversial issue and research in this area is complex for ethical and practical reasons. A review of some critical aspects, giving special attention to those areas that require further research, is therefore timely.

RECENT FINDINGS

There is a dearth of evidence regarding sedation in the setting of palliative care. The literature contains many expert opinions and retrospective reports, but only a few prospective studies have been published. Terminology regarding sedation is confusing, indications and outcomes do not tend to be clearly reported, and no comparative studies to test drug effectiveness have been conducted. Consensus and innovative methodologies to enhance scientific knowledge are urgently needed in this area.

SUMMARY

This review addresses recent literature concerning definitions of palliative sedation and intolerable/refractory suffering, indications and drug use. The current state of the art is summarized and future lines of research are proposed.

Measuring Quality of Dying in End-Stage Renal Disease

Palliative medicine operates under the presumption that it is possible to improve the quality of a patient's death. Nephrology has justifiably taken pride in its reliance on internal benchmarking and the use of quality targets to shape clinical practice innovations, and this article discusses the efforts that are being made to measure end-of-life care of dialysis patients. A tool called the Dialysis Quality of Dying Apgar is described that examines five domains (pain, nonpain symptoms, advance care planning, peacefulness, and time) which are scored and then summed. A recent interdisciplinary workgroup of renal professionals has commissioned a series of focus groups that have attempted to ascertain patient and family values and preferences for the management of terminal situations. The results are summarized, and they should hopefully form a basis for the development of additional research and clinical measurement tools.

End of life issues

Despite advances in cancer survival rates, end of life care remains a vital aspect of cancer management. The use of integrated care pathways can facilitate effective care of dying patients in a generalist setting. However, it remains important that staff are able to recognise the onset of the dying process, not only in order to make symptom control provision, but also that appropriate communication can occur with patients and those close to them. This allows the exercise of choice over place and style of care. The key symptoms at the end of life are restlessness, agitation, breathlessness, pain and noisy respiration from retained airway secretions. Ethical tensions arise from the assumptions that the use of opioids and sedatives hastens dying, but this is contradicted by available evidence.

The effect of the Liverpool Care Pathway for the dying: a multi-centre study

We studied the effect of the Liverpool Care Pathway (LCP) on the documentation of care, symptom burden and communication in three health care settings. Between November 2003 and February 2005 (baseline period), the care was provided as usual. Between February 2005 and February 2006 (intervention period), the LCP was used for all patients for whom the dying phase had started. After death of the patient, a nurse and a relative filled in a questionnaire. In the baseline period, 219 nurses and 130 relatives filled in a questionnaire for 220 deceased patients. In the intervention period, 253 nurses and 139 relatives filled in a questionnaire for 255 deceased patients. The LCP was used for 197 of them. In the intervention period, the documentation of care was significantly more comprehensive compared with the baseline period, whereas the average total symptom burden was significantly lower in the intervention period. LCP use contributes to the quality of documentation and symptom control.

Intravenous morphine consumption in outpatients with cancer during their last week of life--an analysis based on patient-controlled analgesia data

INTRODUCTION

Studies on opioid use in terminally ill cancer patients have shown a prefinal dose increase in the majority of patients. Mostly oral opioids were used. Due to the pharmacokinetic properties of opioids, it is rather difficult to get a reliable estimate of the true opioid need from those results.

MATERIALS AND METHODS

Retrospectively, we analyzed opioid use during the last week of life of 30 consecutive outpatients with cancer on intravenous (i.v.) morphine patient-controlled analgesia (PCA). A dose increase (decrease) was defined as an increase (decrease) of the patient's individual daily dose by at least 30% with respect to their prior daily dose. We also analyzed circadian variations in morphine use.

RESULTS

Thirty patients fulfilled the primary study inclusion criteria. Fulfilling the exclusion criteria, seven patients had to be excluded from analysis (n = 3, on PCA for less than 7 days; n = 4, PCA was finished before death). Twenty-three patients with a total of 161 treatment days were analyzed. The patients' median age was 57 years (range, 4 to 72). The median duration of intravenous morphine PCA was 19 days (range, 8 to 58). The median daily intravenous morphine dose during the last week of life was 96 to 115 mg, without significant change over time/from day to day (Friedman test). On 144/161 days (89.2%), morphine dose remained stable. On 9 treatment days (5.6%), the dose increased, and on 8 days (5.0%), it decreased. In three patients, only dose increases, and in four patients, only dose decreases were observed. In four patients, both dose increases and decreases were observed. Twelve patients showed no change in daily morphine dose. Opioid use lacked a diurnal pattern.

CONCLUSION

During their end-of-life phase, cancer patients on i.v. morphine PCA showed a stable daily opioid need.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years

BACKGROUND

Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer.

PATIENTS AND METHODS

A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses.

RESULTS

Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%).

CONCLUSION

Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.

Palliative Sedation Therapy in the Last Weeks of Life: A Literature Review and Recommendations for Standards

PURPOSE

Palliative sedation therapy (PST) is a controversial issue. There is a need for internationally accepted definitions and standards.

METHODS

A systematic review of the literature was performed by an international panel of 29 palliative care experts. Draft papers were written on various topics concerning PST. This paper is a summary of the individual papers, written after two meetings and extensive e-mail discussions.

RESULTS

PST is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness, using appropriate drugs carefully titrated to the cessation of symptoms. The initial dose of sedatives should usually be small enough to maintain the patients' ability to communicate periodically. The team looking after the patient should have enough expertise and experience to judge the symptom as refractory. Advice from palliative care specialists is strongly recommended before initiating PST. In the case of continuous and deep PST, the disease should be irreversible and advanced, with death expected within hours to days. Midazolam should be considered first-line choice. The decision whether or not to withhold or withdraw hydration should be discussed separately. Hydration should be offered only if it is considered likely that the benefit will outweigh the harm. PST is distinct from euthanasia because (1) it has the intent to provide symptom relief, (2) it is a proportionate intervention, and (3) the death of the patient is not a criterion for success. PST and its outcome should be carefully monitored and documented.

CONCLUSION

When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.

Comparison of Medical Treatments for the Dying in a Hospice and a Geriatric Hospital in Japan

CONTEXT

Most older adults who die in Japan do so in the hospital without receiving hospice or palliative care. While there are some hospices in Japan, little is known about the care they provide to the elderly.

OBJECTIVE

To clarify how the care of dying patients differs in a hospice and a geriatric hospital in Japan.

DESIGN

Cohort study.

SETTING

A hospice and a geriatric hospital in Japan.

PARTICIPANTS

One hundred ninety-one inpatients aged 65 or older.

MAIN OUTCOME

Areas of our interest: (1) gender and age; (2) primary disease(s) and cause of death; (3) observed symptoms/conditions and medical treatment or care conducted within 48 hours prior to death; (4) the actual topics leading to disclosure; and (5) whether or not advance directives had been given.

RESULTS

The X2 test determined that there were statistically significant differences between a geriatric hospital and a hospice, with respect to mean age, diagnoses on admission, primary cause of death, symptoms/conditions, and the practice of medical interventions. However, controlling for patient characteristics and assuming a bivariate distribution between the probabilities of choosing a facility and of undergoing a medical procedure, we found that patients at the hospice were more likely to undergo treatment with opioids, urethral catheter, and oral medicine; such patients were less likely to undergo oxygen inhalation, total parenteral nutrition, and other intravenous drips.

CONCLUSION

The hospice examined in this study was similar to the approach regarding medical treatments observed at the geriatric hospital.

Effects of opioids and sedatives on survival in an Australian inpatient palliative care population

AIMS

To assess whether opioid and sedative medication use affects survival (from hospice admission to death) of patients in an Australian inpatient palliative care unit.

BACKGROUND

Retrospective audit. Newcastle Mercy Hospice--a tertiary referral palliative care unit. All patients who died in the hospice between 1 February and 31 December 2000.

METHODS

Length of survival from hospice admission to death, and the median and mean doses of opioids and sedatives used in the last 24 h of life. Comparison of these with published studies outside of Australia.

RESULTS

In this study, the use of opioids, benzodiazepines and haloperidol did not have an association with shortened survival and the only statistical significant finding was an increased survival in patients who were on 300 mg/day or more of oral morphine equivalent (OME). The proportion of patients requiring greater than or equal to 300 mg OME/day (at 28%) was higher than published studies, but the mean dose of 371 mg OME/day was within the range of other studies. The proportion of patients receiving sedatives (94%) was higher than other studies, but the median dose of parenteral midazolam equivalent of 12.5 mg per 24 h was lower than other studies from outside Australia.

CONCLUSIONS

There was no association between the doses of opioids and sedatives on the last day of life and survival (from hospice admission to death) in this population of palliative care patients.

The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhône-Alpes' region

A prospective survey of five palliative care units in the Rhône-Alpes region of France over a six-month period identified 13 requests for euthanasia (from the patient, family or both). The frequency of the request was low at 2.1% (of 611 patients). We have sought to establish the reasons for this request from the patient or family and the follow up of this request over time.

A concept analysis of dignity for older adults

BACKGROUND

Human dignity is an essential value of professional nursing education as well as a component of the American Nurses Association Code of Ethics. Nurses are exhorted to treat patients with dignity, and older adults want to be treated with dignity and die with dignity. Although dignity, particularly the dignity of older adults, is often discussed in the health care literature, its meaning is not always clear.

AIM

The aim of this paper is to describe a concept analysis to develop a definition of dignity in older adults.

METHODS

Data were collected using a literature review and five focus groups composed of older adults. The literature provided data about professionals' ideas of dignity and the focus groups provided qualitative data about the nature of dignity in older people. The literature review and focus groups were carried out concurrently, followed by synthesis of the findings.

FINDINGS

Dignity is an inherent characteristic of being human, it can be subjectively felt as an attribute of the self, and is made manifest through behaviour that demonstrates respect for self and others. Dignity must be learned, and an individual's dignity is affected by the treatment received from others.

CONCLUSIONS

A behavioural definition of dignity was constructed and this could provide the theoretical basis for nurses to develop interventions that foster dignity for older people.

Stress of dying is not suppressed by high-dose morphine or by dementia

Hypothalamo-pituitary-adrenal (HPA)-axis activation is a response of the organism to psychological and physical stress, resulting in elevated levels of glucocorticoids, mainly cortisol in humans. In our previous studies we found post-mortem blood and cerebrospinal fluid (CSF) cortisol levels to be up to 20-fold higher than in vivo levels. Since clinical observations point to similar strong elevations of cortisol in fatally ill patients, we suggested that the high post-mortem cortisol levels might be due to the stress during the process of dying. We hypothesized that if the cortisol rise during dying is due to the psychological stress of the impending death, then the rise in cortisol should be inversely proportional to the degree of dementia, and that high-dose morphine giving analgesia, sedation, and sleep would suppress this response. Therefore, we measured the cortisol levels by radioimmunoassay (RIA) in the post-mortem CSF of 85 Alzheimer patients and 52 controls. In addition, post-mortem serum cortisol of 17 subjects from the Alzheimer group and nine from the control group were measured. The Alzheimer patients were subdivided according to their degree of dementia, as scored on the Reisberg Scale, before their death. All groups were further analyzed for the effect of morphine treatment, as well as for the effects of the confounding factors like age, gender, time, and season of death. Alzheimer patients had significantly higher cortisol levels than controls, both in CSF (mean (nmol/l)+/-SEM: 482+/-32 vs 285+/-30, respectively, p<0.001) and in serum (2854+/-279 vs 1533+/-395, p=0.011). Mean CSF cortisol level of the severely demented Alzheimer group was even significantly higher than that of mildly demented group (508+/-35 vs 225+/-65, p=0.024) and controls (p<0.001). Cortisol levels correlated positively with the degree of dementia in the Alzheimer group (r=0.236, p=0.035). High-dose morphine did not cause a suppression of cortisol rise, neither in controls nor in Alzheimer patients. Our results indicate that the extreme elevations of cortisol levels during dying are rather due to the organic stress of the organism than to psychological stress of the patient, and is not suppressed by high-dose morphine.

The Last Forty-Eight Hours of Life in a Portuguese Palliative Care Unit: Does it Differ from Elsewhere?

The last few days of life have received significant attention in the literature. Reports have shown similarities and differences between programs. As a palliative care service in a cultural context that has not been reported on, we thought that an audit of our own experience in the care of patients in the last 48 hours of life and a comparison with other programs would be important. A prospective audit was designed to record data for four general domains: general demographic information, symptom prevalence, patient performance status, and perceived level of comfort. The inclusion criteria of patients were: older than 15 years of age (an admission criterion for patients of the unit), diagnosis of cancer, no active cancer-direct treatments, and patients who were on the unit for longer than 48 hours. The audit was completed when the 300th eligible patient died in the unit. Twenty-nine of 300 patients (9.6%) required sedation and the most common cause was delirium. Morphine was the most widely prescribed medication (85% of patients). The subcutaneous route was utilized extensively. Only 12% of the patients received parenteral fluids, usually via hypodermoclisis. Death was considered by staff to have been peaceful in 86% of cases. Our practice appears to mirror that of other palliative care groups.

Impaired communication capacity and agitated delirium in the final week of terminally ill cancer patients: prevalence and identification of research focus

The maintenance of intellectual activity is an important area in the "good death" concept. To clarify the communication capacity levels of terminally ill cancer patients in their final week, and to identify factors contributing to the development of communication capacity impairment and agitated delirium, a retrospective study was performed on 284 consecutive hospice inpatients. The data were collected by chart review, and two independent raters measured the degree of communication capacity and agitation in the last week, using multiple items from the Memorial Delirium Assessment Scale, the Communication Capacity Scale, and the Agitation Distress Scale. The percentages of patients who could achieve complex communication were 43%, 28%, and 13% at 5 days, 3 days, and 1 day before death, respectively. Agitated delirium was identified in 20%. Patients receiving opioids at a dose of > or =120 mg oral morphine equivalents/day one week before death were significantly unable to communicate clearly 3 days before death (0.48 [0.28-0.84], P=0.011). Male gender and the presence of icterus were identified as significant contributors to the development of agitated delirium (odds ratios [95% C.I.]=2.6 [1.4-5.0], P<0.01; 2.4 [1.3-4.4], P< 0.01). These findings demonstrate that communication capacity impairment and agitated delirium are frequently observed in terminally ill cancer patients, and are significantly correlated with a higher dose requirement of opioids and the presence of icterus. To explore the best management to maintain the intellectual activity of dying patients, research should focus on a homogeneous sample of patients receiving high-dose opioids and those with hepatic encephalopathy. In the meanwhile, clinicians should educate patients and family members about the nature of the dying process and help facilitate the completion of life purposes requiring complex mental activities before the latest stages of cancer.

The use of opioids and sedatives at the end of life

Opioids and sedative drugs are commonly used to control symptoms in patients with advanced cancer. However, it is often assumed that the use of these drugs inevitably results in shortening of life. Ethically, this outcome is excused by reference to the doctrine of double effect. In this review, we assess the evidence for patterns of use of opioids and sedatives in palliative care and examine whether the doctrine of double effect is needed to justify their use. We conclude that patients are more likely to receive higher doses of both opioids and sedatives as they get closer to death. However, there is no evidence that initiation of treatment, or increases in dose of opioids or sedatives, is associated with precipitation of death. Thus, we conclude that the doctrine of double effect is not essential for justification of the use of these drugs, and may act as a deterrent to the provision of good symptom control.

Caregivers' satisfaction with hospice care in the last 24 hours of life

The goals of this study were to identify elements of care that contributed to positive and negative perceptions of hospice care in the last 24 hours of life, and to define patient and family characteristics that are associated with satisfaction with care during this difficult period. Surveys were sent to 207 primary caregivers, and 112 surveys were returned. This study reports four findings that elucidate the factors that make family members more or less satisfied with the care that their loved one received during the last day of life, and how satisfaction with this period of care should be measured.

An exploration of dignity in palliative care

This paper presents a qualitative study exploring the meaning of 'dignity' to patients, relatives and professionals. It examines the impact of advanced illness and treatment and the issues pertinent to caring for dignity. Depth interviews were conducted with eight patients, six relatives and seven members of the multiprofessional team. A phenomenological approach to data analysis was adopted. Dignity was found to be a complex phenomenon. It is composed of the dimensions 'being human', 'having control', 'relationship and belonging' and 'maintaining the individual self'. These dimensions seemed to be held in equilibrium by each individual. The importance of each may alter in response to threats to dignity such as advancing illness and how one is treated within it, in an attempt to cope and adapt. Caring for dignity is challenging because it involves balancing the multiple needs of both users and providers of palliative care and the different perceptions and dimensions of dignity itself.

An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care

Functional benchmarking assesses performance and practice across a broad range of settings and carries the potential to effect change in practice. An integrated care pathway (ICP) can assist in the benchmarking process, defining desired outcomes for specific patient groups over a designated time frame. Any variations to the agreed course of care are documented using the 'variance sheet'. This article describes the Wales-wide implementation of an ICP for the last two days of life. The project has enabled an ongoing centralized collection and analysis of variance sheets, which reflect the care of the dying patient in four different care settings crossing the voluntary and statutory sectors. Initial analysis of the first 500 variance sheets to be generated by the ICP for the last two days of life indicates that the management of pain, agitation, excess respiratory secretions and mouth care may be problematic. The same problems were experienced across acute, hospice, specialist inpatient units and community care. Closing the audit cycle involves incorporating the information from the variance analysis into clinical practice.

A very good death: measuring quality of dying in end-stage renal disease

A case is presented of an exceptionally good death after discontinuation of dialysis, and the authors trace the evolution of their attempts at measuring quality of dying in patients with end-stage renal disease. The Dialysis Quality of Dying Apgar is based on the pediatric tool for measuring the condition of newborn babies. Previous research with termination of dialysis has revealed that staff, patients, and families characterize a good death as being pain-free, peaceful, and brief. The quality of dying tool has corresponding domains to which it adds advance care planning and non-pain symptoms. Quantification of patient deaths combined with descriptive narratives can be used to establish benchmarks for the provision of terminal care. Very good deaths need to be recognized and valued as goals for palliative medicine.

Location of death in Canada. A comparison of 20th-century hospital and nonhospital locations of death and corresponding population trends

This report compares 20th-century Canadian hospital and nonhospital location-of-death trends and corresponding population mortality trends. One of the chief findings is a hospitalization-of-death trend, with deaths in hospital peaking in 1994 at 80.5% of all deaths. The rise in hospitalization was more pronounced in the years prior to the development of a national health care program (1966). Another key finding is a gradual reduction since 1994 in hospital deaths, with this reduction occurring across all sociodemographic variables. This suggests nonhospital care options are needed to support what may be an ongoing shift away from hospitalized death and dying.

Evaluating the quality of dying and death

We propose a model for evaluating the quality of dying and death based on concepts elicited from literature review, qualitative interviews with persons with and without chronic and terminal conditions, and consideration of desirable measurement properties. We define quality of dying and death as the degree to which a person's preferences for dying and the moment of death agree with observations of how the person actually died, as reported by others. Expected level of agreement is modified by circumstances surrounding death that may prevent following patient's prior preferences. Qualitative data analysis yielded six conceptual domains: symptoms and personal care, preparation for death, moment of death, family, treatment preferences, and whole person concerns. These domains encompass 31 aspects that can be rated by patients and others as to their importance prior to death and assessed by significant others or clinicians after death to assess the quality of the dying experience. The proposed model uses personal preferences about the dying experience to inform evaluation of this experience by others after death. This operational definition will guide validation of after-death reports of the quality of dying experience and evaluation of interventions to improve quality of end-of-life care.

Discourses of the body in euthanasia: symptomatic, dependent, shameful and temporal

This theoretical paper is derived from a discourse analysis of the textual material from a study of the seven deaths associated with legalised euthanasia in the Northern Territory, Australia. The textual analysis utilises evidence from interviews, letters written by people seeking euthanasia, medical reports, coroner's records and media reports concerning the social experiment of legalised euthanasia in Australia. The paper does not discuss the euthanasia debate. It argues that the body is a neglected concern in the debates and offers a construction of the discourses of the body as symptomatic, dependent, shameful and temporal. Medical discourses frame the body as symptomatic but these people were also concerned with the loss of autonomy associated with dependence, with shame connected with loss of bodily functions and the embodied experience of determining a 'time to die'.

Care of the patient close to death

The recognition that the patient is close to death is essential and usually possible. Assessment must be meticulous, goals clearly articulated, and strategies for symptom relief and comprehensive care defined and monitored. Death should not be obstructed by futile measures. The wish of a patient to be allowed to die needs to be respected, as well as a patient's anguish in the face of imminent and unwanted death. The final phase of life (hours or days) should not be seen as a time of treatment failure, but as a time for completion of tasks in peace and dignity, even in the mist of weakness and profound surrender.