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Guité-Verret A, Boivin J, Hanna AMR, Downar J, Bush SH, Marcoux I, Guay D, Tapp D, Lapenskie J, Gagnon B. Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences. BMC Palliat Care 2024; 23:104. [PMID: 38637812 PMCID: PMC11027280 DOI: 10.1186/s12904-024-01426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.
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Affiliation(s)
- Alexandra Guité-Verret
- Department of Psychology, Université du Québec à Montréal, Montréal, Canada
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
| | - Jessica Boivin
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
| | | | - James Downar
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Isabelle Marcoux
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Diane Guay
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Diane Tapp
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bruno Gagnon
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada.
- CHU Québec-Université Laval Research Centre, Québec, Canada.
- Bruyère Research Institute, Ottawa, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, Canada.
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Kremling A, Bausewein C, Klein C, Nadolny S, Ostgathe C, Schildmann E, Ziegler K, Schildmann J. Terminological Confusion About Sedation in Palliative Care: Results of an International Online Vignette Survey. J Palliat Med 2024; 27:487-494. [PMID: 38330403 PMCID: PMC10998700 DOI: 10.1089/jpm.2023.0159] [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] [Accepted: 11/08/2023] [Indexed: 02/10/2024] Open
Abstract
Background: Terminological problems concerning sedation in palliative care and consequences for research and clinical decision making have been reported frequently. Objectives: To gather data on the application of definitions of sedation practices in palliative care to clinical cases and to analyze implications for high-quality definitions. Design: We conducted an online survey with a convenience sample of international experts involved in the development of guidelines on sedation in palliative care and members of the European Association for Palliative Care (EAPC). Participants were asked to apply four published definitions to four case vignettes. Data were analyzed using descriptive statistics. Results: A total of 32 experts and 271 EAPC members completed the survey. The definitions were applied correctly in n = 2200/4848 cases (45.4%). The mean number of correct applications of the definitions (4 points max.) was 2.2 ± 1.14 for the definition of the SedPall study group, 1.8 ± 1.03 for the EAPC definition, 1.7 ± 0.98 for the definition of the Norwegian Medical Association, and 1.6 ± 1.01 for the definition of the Japanese Society of Palliative Medicine. The rate of correct applications for the 16 vignette-definition pairs varied between 70/303 (23.1%) and 227/303 (74.9%). The content of definitions and vignettes together with free-text comments explains participants' decisions and misunderstandings. Conclusions: Definitions of sedation in palliative care are frequently incorrectly applied to clinical case scenarios under simplified conditions. This suggests that clinical communication and research might be negatively influenced by misunderstandings and inconsistent labeling or reporting of data. Clinical Trial Registration Number: DRKS00015047.
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Affiliation(s)
- Alexander Kremling
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
| | - Carsten Klein
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Stephan Nadolny
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
- Institute for Educational and Health-Care Research in the Health Sector, Hochschule Bielefeld—University of Applied Sciences and Arts, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, Ludwig Maximilian University München, Comprehensive Cancer Centre Munich (CCCM), Germany
- Palliative Medicine, Faculty of Medicine, University of Augsburg, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Interdisciplinary Center for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Addressing Challenges With Sedation in End-of-Life Care. J Pain Symptom Manage 2024; 67:346-349. [PMID: 38158164 PMCID: PMC10939822 DOI: 10.1016/j.jpainsymman.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College (Y.A.), New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine (E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee (L.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA; Departments of Medicine and Philosophy (D.P.S.), Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, District of Columbia, USA
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Beauverd M, Mazzoli M, Pralong J, Tomczyk M, Eychmüller S, Gaertner J. Palliative sedation - revised recommendations. Swiss Med Wkly 2024; 154:3590. [PMID: 38579308 DOI: 10.57187/s.3590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.
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Affiliation(s)
- Michel Beauverd
- Service de soins palliatifs et de support, Département de médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Martyna Tomczyk
- Institute of Humanities in Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Steffen Eychmüller
- Universitäres Zentrum für Palliative Care (UZP), Inselspital, University Hospital, Bern, Switzerland
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
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Ostgathe C, Bausewein C, Schildmann E, Bazata J, Handtke V, Heckel M, Klein C, Kremling A, Kurkowski S, Meesters S, Seifert A, Torres Cavazos JL, Ziegler K, Jäger C, Schildmann J. Expert-approved best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care (SedPall). BMC Palliat Care 2023; 22:126. [PMID: 37667303 PMCID: PMC10476406 DOI: 10.1186/s12904-023-01243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND The use of sedative drugs and intentional sedation in end-of-life care is associated with clinical, ethical and legal challenges. In view of these and of the issue's great importance to patients undergoing intolerable suffering, we conducted a project titled SedPall ("From anxiolysis to deep continuous sedation - Development of recommendations for sedation in palliative care") with the purpose of developing best practice recommendations on the use of sedative drugs and intentional sedation in specialist palliative care and obtaining feedback and approval from experts in this area. DESIGN Our stepwise approach entailed drafting the recommendations, obtaining expert feedback, conducting a single-round Delphi study, and convening a consensus conference. As an interdisciplinary group, we created a set of best practice recommendations based on previously published guidance and empirical and normative analysis, and drawing on feedback from experts, including patient representatives and of public involvement participants. We set the required agreement rate for approval at the single-round Delphi and the consensus conference at ≥80%. RESULTS Ten experts commented on the recommendations' first draft. The Delphi panel comprised 50 experts and patient and public involvement participants, while 46 participants attended the consensus conference. In total, the participants in these stages of the process approved 66 recommendations, covering the topics "indications", "intent/purpose [of sedation]", "decision-making", "information and consent", "medication and type of sedation", "monitoring", "management of fluids and nutrition", "continuing other measures", "support for relatives", and "team support". The recommendations include suggestions on terminology and comments on legal issues. CONCLUSION Further research will be required for evaluating the feasibility of the recommendations' implementation and their effectiveness. The recommendations and the suggested terminology may serve as a resource for healthcare professionals in Germany on the use of sedative drugs and intentional sedation in specialist palliative care and may contribute to discussion on the topic at an international level. TRIAL REGISTRATION DRKS00015047 (German Clinical Trials Register).
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Affiliation(s)
- Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University of Augsburg, Stenglinstraße 2, Augsburg, 86156, Germany
| | - Jeremias Bazata
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Violet Handtke
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany.
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Sandra Kurkowski
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Sophie Meesters
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Andreas Seifert
- Paderborn Centre for Educational Research and Teacher Education - PLAZ Professional School, Paderborn University, Warburger Str. 100, 33098, Paderborn, Germany
| | - Jorge Luis Torres Cavazos
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich- Alexander-Universität Erlangen-Nürnberg (FAU), Werner-von-Siemens-Straße 34, Erlangen, 91052, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schillerstraße 1, 91054, Erlangen, Germany
| | - Christian Jäger
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schillerstraße 1, 91054, Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
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Kauzner S, Heckel M, Ostgathe C, Schneider M, Bausewein C, Schildmann E, Kremling A, Ziegler K, Klein C. Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates. J Palliat Med 2023; 26:1277-1284. [PMID: 37155703 DOI: 10.1089/jpm.2022.0476] [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: 05/10/2023] Open
Abstract
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.
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Affiliation(s)
- Saskia Kauzner
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Manuela Schneider
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care and Charité Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Lucchi E, Milder M, Dardenne A, Bouleuc C. Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology. BMC Palliat Care 2023; 22:97. [PMID: 37468913 DOI: 10.1186/s12904-023-01219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 07/03/2023] [Indexed: 07/21/2023] Open
Abstract
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.
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Affiliation(s)
- E Lucchi
- Department of Supportive and Palliative Care, Institut Curie, Saint-Cloud, France.
| | - M Milder
- Department of Clinical Research, Institut Curie, Paris, France
| | - A Dardenne
- Department of Supportive and Palliative Care, Institut Curie, Saint-Cloud, France
| | - C Bouleuc
- Department of Supportive and Palliative Care, Institut Curie, Paris, France
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Response to "The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey''. BMC Palliat Care 2023; 22:18. [PMID: 36872316 PMCID: PMC9987085 DOI: 10.1186/s12904-023-01130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 01/27/2023] [Indexed: 03/07/2023] Open
Abstract
We have several major concerns about this article [Guastella et al 2021]. Although it states that it is about palliative sedation, it is not. Rather, it is about the French Claeys Leonetti Law about Continuous Deep Sedation (CDS) at the end of life [Loi n°2016-87].
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Newcomer K, Merkelz K, Tatum P, Dalton H. Palliative Sedation in the Home Setting #451. J Palliat Med 2023; 26:299-300. [PMID: 36724321 DOI: 10.1089/jpm.2022.0508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Kelley Newcomer
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Kurt Merkelz
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Paul Tatum
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
| | - Heather Dalton
- Fast Facts and Concepts are edited by Sean Marks, MD (Medical College of Wisconsin) and associate editor Drew A. Rosielle, MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Fact's content. The full set of Fast Facts is available at PCNOW with contact information, and how to reference Fast Facts
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Meesters S, Bazata J, Handtke V, Gehrmann J, Kurkowski S, Klein C, Bausewein C, Schildmann E. "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. Palliat Med 2023; 37:140-148. [PMID: 36242514 PMCID: PMC9841818 DOI: 10.1177/02692163221128938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Sophie Meesters
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany.,Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jeremias Bazata
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany
| | - Violet Handtke
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany
| | - Jan Gehrmann
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany.,TUM School of Medicine, Institute of General Practice and Health Services Research, Technical University of Munich, Munich, Germany
| | - Sandra Kurkowski
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carsten Klein
- Department of Palliative Medicine, CCC Erlangen - EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Eva Schildmann
- Department of Palliative Medicine, LMU Klinikum, Munich, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Cancer Immunology, Oncological Palliative Care & Charité Comprehensive Cancer Center, Berlin, Germany
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11
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Tomczyk M, Jaques C, Jox RJ. Clinical Practice Guidelines on Palliative Sedation Around the World: A Systematic Review. J Palliat Care 2022:8258597221138674. [PMID: 36437779 DOI: 10.1177/08258597221138674] [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: 11/29/2022]
Abstract
Objective: The principal aim of this study was to identify, systematically and transparently, clinical practice guidelines (CPGs) on palliative sedation from around the world. Methods: A systematic search was performed using 5 databases, grey literature search tools, citation tracking, and contact with palliative care experts across the world. Current CPGs accredited by an international, national, or regional authority, published in English, German, French, or Italian, were subjected to content analysis. Results: In total, 35 CPGs from 14 countries and 1 international CPG were included in the analysis. The CPGs had diverse formal characteristics. Their thematic scope was difficult to analyze and compare because of differences in the terms and definitions of palliative sedation in those texts. We identified 3 main situations: (1) CPGs with a fully explicit thematic scope; (2) CPGs with a partially explicit thematic scope; and (3) CPGs without an explicit thematic scope. Several CPGs explicitly stated what forms of sedation were excluded from the text. However, this presentation was often confusing. Conclusion: Our review provides several pieces of information that could guide international reflections in this field, and be used to develop or update CPGs at all levels. Efforts should be made to clarify the thematic scope of each CPG on palliative sedation, in order to generate an understanding of the forms of this therapy addressed in the text.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative & Supportive Care Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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12
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Tomczyk M, Jaques C, Jox RJ. Ethical challenges in palliative sedation of adults: protocol for a systematic review of current clinical practice guidelines. BMJ Open 2022; 12:e059189. [PMID: 35777881 PMCID: PMC9252196 DOI: 10.1136/bmjopen-2021-059189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Palliative and Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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13
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Alt-Epping B. Palliative Sedation: Controversial Discussions and Appropriate Practice. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:371-372. [PMID: 36045550 PMCID: PMC9487709 DOI: 10.3238/arztebl.m2022.0212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Bernd Alt-Epping
- Department of Palliative Medicine, University Hospital Heidelberg
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14
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Schildmann E, Meesters S, Bausewein C, Grüne B, Sophie Licher A, Bolzani A, Remi C, Nübling G, Benedikt Westphalen C, Drey M, Harbeck N, Hentrich M, Grüne B. Sedatives and Sedation at the End of Life in the Hospital. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:373-379. [PMID: 35440363 PMCID: PMC9487710 DOI: 10.3238/arztebl.m2022.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/10/2021] [Accepted: 04/05/2022] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Eva Schildmann
- Department of Palliative Medicine, University Hospital, LMU Munich,Oncological Palliative Care, Department of Hematology, Oncology and Cancer Immunology & Charité Comprehensive Cancer Center, Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin,*Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie Onkologische Palliativmedizin Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sophie Meesters
- Department of Palliative Medicine, University Hospital, LMU Munich
| | | | - Bettina Grüne
- Department of Palliative Medicine, University Hospital, LMU Munich
| | | | - Anna Bolzani
- Department of Palliative Medicine, University Hospital, LMU Munich
| | - Constanze Remi
- Department of Palliative Medicine, University Hospital, LMU Munich
| | - Georg Nübling
- Department of Neurologiy, University Hospital, LMU Munich
| | - C. Benedikt Westphalen
- Medizinische Klinik und Poliklinik III, University Hospital, LMU Munich & Comprehensive Cancer Center Munich
| | - Michael Drey
- Department of Internal Medicine IV, Geriatrics, University Hospital, LMU Munich
| | - Nadia Harbeck
- Breast Center, Department of Obstetrics and Gynecology, University Hospital, LMU Munich & Comprehensive Cancer Center Munich
| | - Marcus Hentrich
- Department of Hematology and Oncology, Red Cross Hospital, Munich
| | - Bettina Grüne
- Department of Youth and Youth Services, German Youth Institute (DJI), Munich
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15
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Kremling A, Bausewein C, Klein C, Schildmann E, Ostgathe C, Ziegler K, Schildmann J. Intentional Sedation as a Means to Ease Suffering: A Systematically Constructed Terminology for Sedation in Palliative Care. J Palliat Med 2022; 25:793-796. [PMID: 35073180 PMCID: PMC9081045 DOI: 10.1089/jpm.2021.0428] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alexander Kremling
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Carsten Klein
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Eva Schildmann
- Department of Palliative Medicine Ludwig-Maximilian-Universität, Comprehensive Cancer Centre Munich (CCCM), LMU University Hospital, Munich, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center Erlangen-EMN (CCCER-EMN), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Erlangen, Germany
| | - Kerstin Ziegler
- Department of Criminal Law, Criminal Procedural Law, Commercial Criminal Law and Medical Criminal Law, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
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16
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Twycross RG, Wong AKY, Vivat B. Comment on Ramos-Rincon et al. Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study. Medicina 2021, 57, 873. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010082. [PMID: 35056390 PMCID: PMC8778193 DOI: 10.3390/medicina58010082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/30/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
Abstract
We read with interest the article by Ramos-Rincon and colleagues about patients with COVID-19 dying in acute medical wards in a Spanish University hospital [...].
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Affiliation(s)
| | - Aaron Kee Yee Wong
- Department of Palliative Care, The Royal Melbourne Hospital, 300 Gratton Street, Parkville, VIC 3050, Australia;
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.,Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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Koksvik GH, Richards N, Gerson SM, Materstvedt LJ, Clark D. Medicalisation, suffering and control at the end of life: The interplay of deep continuous palliative sedation and assisted dying. Health (London) 2020; 26:512-531. [PMID: 33307828 PMCID: PMC9163770 DOI: 10.1177/1363459320976746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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’.
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