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Cuviello A, Ang N, Morgan K, Baker JN, Anghelescu DL. Palliative Sedation Therapy Practice Comparison - A Survey of Pediatric Palliative Care and Pain Management Specialists. Am J Hosp Palliat Care 2023; 40:977-986. [PMID: 36475873 DOI: 10.1177/10499091221138298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children's hospitals. The distribution between PPC and pediatric pain management specialists' responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.
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Affiliation(s)
| | - Nicholas Ang
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Kyle Morgan
- University of Tennessee Health Science Center, Memphis, TN, USA
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Garcia ACM, Isidoro GM, Paiva EMDC, Silva AE, Costa ICP, Bornemann-Cimenti H. Palliative Sedation at Home: A Scoping Review. Am J Hosp Palliat Care 2023; 40:173-182. [PMID: 35466700 DOI: 10.1177/10499091221096412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Palliative Sedation (PS) is an effective measure for the relief of refractory symptoms in end-of-life patients. This intervention can be performed at home, respecting the patients' and their families' decisions. A scoping review was performed to map the available evidence in the literature on the performance of PS at home. This review included 23 studies. Most were conducted in European countries with adult cancer patients. Patients, family members and healthcare providers participated in the decision making regarding the use of PS at home. PS was used primarily to manage refractory symptoms (pain, delirium, dyspnea, and others), and in 1 of the studies PS was mentioned as a possible intervention for shortening life. The most commonly used medication was midazolam and the average duration ranged from 4 h to 7 days. There are few reports on adverse events related to PS. This intervention seems to be a feasible possibility for the management of refractory symptoms in patients at the end of life, despite the fact that it can represent specific challenges for healthcare providers, patients and families. However, the literature is limited regarding PS in children and in people with diseases other than cancer, as well as on the evaluation of possible adverse effects related to this intervention. Furthermore, it is essential to have a broad ethical, clinical and legal debate on whether to consider the use of PS for the purpose of shortening life in specific cases.
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Affiliation(s)
| | | | | | - Alexandre E Silva
- Nursing Department - Campus Centro-Oeste Dona Lindu, 74383Federal University of São João del-Rei, Divinópolis, Brazil
| | | | - Helmar Bornemann-Cimenti
- Departement of Anesthesiology and Intensive Care Medicine, 31475Medical University of Graz, Graz, Austria
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de Noriega I, Martino Alba R, Herrero Velasco B, Madero López L, Lassaletta Á. Palliative care in pediatric patients with central nervous system cancer: Descriptive and comparative study. Palliat Support Care 2022; 21:1-8. [PMID: 35957581 DOI: 10.1017/s1478951522001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Data regarding the palliative needs of pediatric patients with central nervous system (CNS) cancer are scarce. We aimed to describe the attention provided by a pediatric palliative care (PPC) team to patients with CNS cancer and the differences in care compared to patients who did not receive PPC. METHOD This retrospective study was based on the clinical records of deceased patients with CNS cancer attended by a PPC team over 10 years, analyzing their trajectory and provision of PPC, including medical, psychological, social, and nursing interventions. Furthermore, we compared the last month of life care of deceased patients with CNS cancer in the same institution, based on whether they were attended by the PPC team. RESULTS Of 71 patients, 59 received PPC, with a median of 1.6 months (Interquartile range: 0.6-5.2) from referral to death. Home hospitalization was provided to 84.8%, nursing interventions were registered in 89.8%, psychological characteristics in 84.7%, and social interventions in 88.1%. The most common symptoms were pain, dyspnea, and constipation. When comparing patients from the same hospital who received PPC (n = 36) with those who did not (n = 12), the former spent fewer days in the hospital in their last month and last week (p < 0.01) and were more likely to die at home (50% vs. 0%; p < 0.01). SIGNIFICANCE OF RESULTS Patients with CNS cancer show various medical, social, and psychological needs during end-of-life care. Providing specific PPC interventions decreased the number of days spent at the hospital and increased the rate of death at home.
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Affiliation(s)
- Iñigo de Noriega
- Pediatric Palliative Care Unit, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Ricardo Martino Alba
- Pediatric Palliative Care Unit, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Blanca Herrero Velasco
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Luis Madero López
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Álvaro Lassaletta
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
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García-Quintero X, Claros-Hulbert A, Tello-Cajiao ME, Bolaños-Lopez JE, Cuervo-Suárez MI, Durán MGG, Gómez-García W, McNeil M, Baker JN. Using EmPalPed-An Educational Toolkit on Essential Messages in Palliative Care and Pain Management in Children-As a Strategy to Promote Pediatric Palliative Care. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9060838. [PMID: 35740775 PMCID: PMC9221893 DOI: 10.3390/children9060838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/23/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022]
Abstract
Background: Most children needing palliative care (PC) live in low- and middle-income countries. In Colombia, pediatric palliative care (PPC) knowledge among healthcare professionals (HCPs) is lacking as PPC is not included in the educational curricula of healthcare programs. Therefore, specific training that improves knowledge of HCPs and access to PC for children and their families is needed. To address this gap, we organized and conducted the Essential Messages in Palliative Care and Pain Management in Children (EmPalPed), an educational toolkit to increase awareness and promote essential knowledge in PPC for low- and middle-income countries. Methodology: The EmPalPed toolkit consisted of a 5-h virtual workshop with small working groups of HCPs caring for children with life-threatening conditions such as cancer. The toolkit was organized along five key domains: (1) PC as it relates to the concept of quality of life (QoL), (2) effective communication, (3) addressing pain management as a top priority, (4) providing end-of-life care, and (5) access to high-quality PC as a fundamental human right. The workshop activities included different educational strategies and tools (e.g., a pocket guide for pain assessment and management, a PPC booklet, a quick guide for communicating bad news, role playing, and discussions of clinical cases). Results: A total of 145 HCPs from 22 centers were trained. The post-test analysis for HCPs showed that attitude and knowledge about communication (p < 0.001), pain assessment (p < 0.001), first-line opioid of choice in children (p < 0.001), and palliative sedation (p < 0.001) had positive and statistically significant changes from the pre-test analysis. Discussion: This study supported the notion that the EmPalPed educational toolkit is an effective mechanism for raising awareness regarding PPC as well as providing training in many of the key aspects of PPC. The EmPalPed training approach should be studied beyond this setting, and the impact should be measured longitudinally.
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Affiliation(s)
- Ximena García-Quintero
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali 760032, Colombia;
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS #260, Memphis, TN 38105, USA; (J.N.B.); (M.M.)
- Correspondence: ; Tel.: +1-(954)-290-1804
| | - Angélica Claros-Hulbert
- Faculty of Health Sciences, Universidad de la Sabana, Chia 250001, Colombia;
- Palliative Care Department, Instituto Nacional de Cancerología, Bogotá 111511, Colombia
| | | | - Jhon Edwar Bolaños-Lopez
- Dirección de Investigación y Desarrollo, Centro de Biociencias, Seguros SURA Colombia, Medellín 050021, Colombia;
| | - María Isabel Cuervo-Suárez
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali 760032, Colombia;
- Faculty of Health Sciences Department, Clinical Medical Science, Universidad Icesi, Cali 760031, Colombia
| | - Martha Gabriela García Durán
- Psycho-Oncology Service, Hospital Pediátrico de Sinaloa “Dr. Rigoberto Aguilar Pico”, Culiacán 80200, Sinaloa, Mexico;
| | - Wendy Gómez-García
- Dr. Robert Reid Cabral Children’s Hospital, Santo Domingo 10107, Dominican Republic;
| | - Michael McNeil
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS #260, Memphis, TN 38105, USA; (J.N.B.); (M.M.)
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS #260, Memphis, TN 38105, USA; (J.N.B.); (M.M.)
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5
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Descriptive analysis of palliative sedation in a pediatric palliative care unit. An Pediatr (Barc) 2022; 96:385-393. [DOI: 10.1016/j.anpede.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/06/2021] [Indexed: 11/21/2022] Open
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6
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Palliative sedation for children at end of life: a retrospective cohort study. BMC Palliat Care 2022; 21:57. [PMID: 35473555 PMCID: PMC9044579 DOI: 10.1186/s12904-022-00947-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background Palliative sedation is consciously reducing the patient’s consciousness to alleviate the refractory symptoms. However, studies on palliative sedation for children are scarce. We aimed to survey the symptom control and risks for children with sedative therapy in end of life. Method This study was a single center retrospective cohort study. Children who died in the Department of Palliative Medicine were divided into palliative sedation (Group A) and non-palliative sedation group (Group B). The symptoms relief, survival time, and last hospitalization time were compared between two groups. Results From January 2012 to November 2019, 41 children died in department of palliative care. 24 children were sedated (Group A), meanwhile 17 children were not (Group B). The symptoms in Group A were more complex than Group B (p = 0.013). Overall symptom relief in Group A was higher than that in Group B (24/24, 10/15 p = 0.041). Pain relief rates (7/7, 20/21 p = 0.714), maximum/pre-death opioid dose [30(20, 77.5), 18(9, 45) p = 0.175, 30(20, 60), 18(9, 45) p = 0.208] and pain intensity difference [5(4,6.5), 4(2,6) p = 0.315] did not differ significantly in either groups. After diagnosis, the survival time of the Group A was longer than the Group B (p = 0.047). However, the length of hospitalization before death was similar in two groups (p = 0.385). Conclusion Palliative sedation controls complicated, painful symptoms at the end of life and does not shorten the hospitalization time in children.
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Broden EG, Werner-Lin A, Curley MA, Hinds RPS. Shifting and intersecting needs: Parents’ experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit. Intensive Crit Care Nurs 2022; 70:103216. [DOI: 10.1016/j.iccn.2022.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
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Juárez-Villegas LE, Altamirano-Bustamante MM, Zapata-Tarrés MM. Decision-Making at End-of-Life for Children With Cancer: A Systematic Review and Meta-Bioethical Analysis. Front Oncol 2021; 11:739092. [PMID: 34722289 PMCID: PMC8554195 DOI: 10.3389/fonc.2021.739092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Evidence shows that medical education includes a variety of basic and clinical skills. Ethical and human values are not typically considered in medical school curricula, and this is evident in medical practice in certain scenarios such as decision-making at pediatric cancer patients' end of life. Methods This study explores a bioethical approach to address complex decision-making at the end of life in children and adolescents with cancer. We are a cross-functional group of scientists from several academic disciplines who conducted a systematic review of the literature using our newly developed meta-bioethical analysis and synthesis of findings. The search was carried out in five databases, resulting in 10 research papers. Following quality screening, seven articles were ultimately selected for further analysis. Results Our focus is on the state of the art to better understand the bioethical deliberation at the end of life in pediatric oncology. Here, we report a systematic review that includes (i) classification of the screened articles by the type of decision-making they use, ii) the system values that are at the core of the decision-making at the end of life, and iii) bioethical and ethical discernment queries. We conclude with a discussion regarding the best practices of ethical discernment and decision-making at the end of life.This study highlights the need to develop more research to better understand the influence and origin of these multidimensional factors determining critical decisions that define the quality of life of patients in a highly sensitive moment. Conclusion We conclude that personal aspects of the physician define their actions more than knowledge or organized structure. It is thus necessary that pediatric oncologists receive ethics and humanistic education.
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Affiliation(s)
- Luis Enrique Juárez-Villegas
- Department of Hematology-Oncology, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico.,Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Myriam M Altamirano-Bustamante
- Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Metabolic Diseases Research Unit, Cross-functional Bioethics Group, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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9
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de Noriega I, Rigal Andrés M, Martino Alba R. [Descriptive analysis of palliative sedation in a pediatric palliative care unit]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00009-6. [PMID: 33612453 DOI: 10.1016/j.anpedi.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/14/2020] [Accepted: 01/06/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Data surrounding palliative sedation in pediatric patients is scarce. Our objective is to assess the utility of creating a quality standard for pediatric palliative sedation. MATERIAL AND METHODS A non-systematic review of the literature was used to find recommendations for pediatric palliative sedation, after which a definition was established based on three items: (1) indication, (2) consent, and (3) application. Afterwards, a retrospective analysis of palliative sedations applied by our unit over 5 years was performed. RESULTS Out of 163 patients, palliative sedation was applied in 20, in 17 of them by our unit (14/20 males; median: 11.9 years). Twelve patients had oncological diseases, seven had neurological conditions, and one had a polymalformative syndrome. Nine patients had more than one symptom at the time of PS initiation with pain (11/17) and dyspnoea (10/17) being the most frequent. As for the definition, only three patients achieved a global completion, with the registration of the consent, specification of refractoriness and the establishment of an adequate initial sedative dose being the areas with more possible improvement. CONCLUSIONS The application of the definition allowed us to analyze and find areas of improvement for our clinical practice of palliative sedation in pediatric patients.
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Affiliation(s)
- Iñigo de Noriega
- Servicio de Pediatría. Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, España.
| | - Manuel Rigal Andrés
- Unidad de Atención Integral Paliativa Pediátrica. Hospital Infantil Universitario del Niño Jesús, Madrid, España
| | - Ricardo Martino Alba
- Unidad de Atención Integral Paliativa Pediátrica. Hospital Infantil Universitario del Niño Jesús, Madrid, España
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Brouwer M, Kaczor C, Battin MP, Maeckelberghe E, Lantos JD, Verhagen E. Should Pediatric Euthanasia be Legalized? Pediatrics 2018; 141:peds.2017-1343. [PMID: 29317518 DOI: 10.1542/peds.2017-1343] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 11/24/2022] Open
Abstract
Voluntary active euthanasia for adults at their explicit request has been legal in Belgium and the Netherlands since 2002. In those countries, acceptance of the practice for adults has been followed by acceptance of the practice for children. Opponents of euthanasia see this as a dangerous slippery slope. Proponents argue that euthanasia is sometimes ethically appropriate for minors and that, with proper safeguards, it should be legally available in appropriate circumstances for patients at any age. In this Ethics Rounds, we asked philosophers from the United States and the Netherlands, and a Dutch pediatrician, to discuss the ethics of legalizing euthanasia for children.
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Affiliation(s)
- Marije Brouwer
- Institute for Medical Education and.,Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Christopher Kaczor
- Department of Philosophy, Loyola Marymount University, Los Angeles, California
| | - Margaret P Battin
- Department of Philosophy, University of Utah, Salt Lake City, Utah; and
| | | | | | - Eduard Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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11
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Johnson LM, Frader J, Wolfe J, Baker JN, Anghelescu DL, Lantos JD. Palliative Sedation With Propofol for an Adolescent With a DNR Order. Pediatrics 2017; 140:peds.2017-0487. [PMID: 28679640 DOI: 10.1542/peds.2017-0487] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
Death from cancer is often painful. Usually, the pain can be relieved in ways that allow patients to remain awake and alert until the end. Sometimes, however, the only way to relieve pain is to sedate patients until they are unconscious. This method has been called palliative sedation therapy. Palliative sedation therapy is controversial because it can be misunderstood as euthanasia. We present a case in which an adolescent who is dying of leukemia has intractable pain. Experts in oncology, ethics, pain management, and palliative care discuss the trade-offs associated with different treatment strategies.
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Affiliation(s)
- Liza-Marie Johnson
- Division of Oncology Hospitalist Medicine, St. Jude's Hospital and Research Center, Memphis, Tennessee
| | - Joel Frader
- Pediatric Palliative and End-of-Life Care, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Joanne Wolfe
- Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatric Palliative Care, Boston Children's Hospital, Boston, Massachusetts; and
| | - Justin N Baker
- Division of Oncology Hospitalist Medicine, St. Jude's Hospital and Research Center, Memphis, Tennessee
| | - Doralina L Anghelescu
- Division of Oncology Hospitalist Medicine, St. Jude's Hospital and Research Center, Memphis, Tennessee
| | - John D Lantos
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
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12
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Splinter W. Pediatric Palliative Care. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Lux MR, Protus BM, Kimbrel J, Grauer P. A Survey of Hospice and Palliative Care Physicians Regarding Palliative Sedation Practices. Am J Hosp Palliat Care 2016; 34:217-222. [DOI: 10.1177/1049909115615128] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context: Patients nearing the end of life may experience symptoms that are refractory to standard therapeutic options. Physicians may consider palliative sedation to relieve intolerable suffering. There is limited clinical literature regarding preferred medications for palliative sedation. Objectives: To determine the preferred medications physicians use when implementing palliative sedation. Methods: An Internet-based, cross-sectional survey of hospice and palliative care physicians in the United States. Results: A link to the survey was e-mailed to 3130 physician members of the American Academy of Hospice and Palliative Medicine, of which 381 physicians completed the survey. Physicians were not required to answer all questions. Nearly all (n = 335, 99%) respondents indicated that palliative sedation may be used (acceptable by 73% [n = 248] for refractory symptoms and acceptable by 26% [n = 87] only for imminently dying patients). Seventy-nine percent (n = 252) believed that opioids should not be used to induce palliative sedation but should be continued to provide pain control. Midazolam was the most commonly selected first-line choice for palliative sedation (n = 155, 42%). The most commonly reported second-line agents for the induction of palliative sedation were lorazepam, midazolam (for those who did not select midazolam as first-line agent), and phenobarbital with a reported preference of 20% (n = 49), 19% (n = 46), and 17% (n = 40), respectively. Conclusion: Of the physicians surveyed, 99% (n = 335) felt that palliative sedation is a reasonable treatment modality. Midazolam was considered a drug of choice for inducing and maintaining sedation, and opioids were continued for pain control.
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Affiliation(s)
| | - Bridget McCrate Protus
- HospiScript, a Catamaran Company, The Ohio State University College of Pharmacy, Dublin, OH, USA
| | - Jason Kimbrel
- HospiScript, a Catamaran Company, The Ohio Northern University College of Pharmacy, Dublin, OH, USA
| | - Phyllis Grauer
- HospiScript, a Catamaran Company, The Ohio State University College of Pharmacy, Dublin, OH, USA
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