1
|
Hwang IC. Current Status and Future Directions of Research on Palliative Sedation. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2022; 25:193-197. [PMID: 37674671 PMCID: PMC10179994 DOI: 10.14475/jhpc.2022.25.4.193] [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: 10/05/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 09/08/2023]
Abstract
Patients with terminal cancer experience very severe symptoms during the end of life, and palliative sedation (PS) may be considered if those symptoms are refractory to any other treatment. This brief report presents ethical considerations, practices, and recent concerns on PS. PS is quite different from euthanasia. There is a lack of consensus and standards on protocols, but its notable effects have been reported in hospice care settings. Most studies to date have reported no difference in survival between patients receiving PS and those not, and PS must be conducted proportionally with the lightest level of sedation. The most common indication for PS is delirium, and midazolam is the main sedative used. It is recommended that information regarding PS should be provided to patients and their caregivers repeatedly as early as possible. Existential suffering alone is not an indication for PS, and there is a lack of evidence on bispectral analysis. Additional research on PS is needed in Korea.
Collapse
Affiliation(s)
- In Cheol Hwang
- Department of Family Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| |
Collapse
|
2
|
Family experience of palliative sedation therapy: proportional vs. continuous deep sedation. Support Care Cancer 2022; 30:3903-3915. [PMID: 35039967 DOI: 10.1007/s00520-021-06745-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Some patients experience intense symptoms refractory to intensive palliative care, and palliative sedation is sometimes used. Palliative sedation may be classified into proportional and continuous deep sedation (CDS). The primary aim of this study was to compare family experience between families of patients who received proportional or CDS. METHODS A multicenter questionnaire survey was conducted involving bereaved families of cancer patients who received proportional or CDS based on a sedation protocol. Overall evaluation of sedation (satisfaction, family-perceived distress, appropriateness of timing, and patient distress) and 13-item family concerns, good death, satisfaction with care, depression, quality of care, unfinished business, and balance between symptom relief and maintaining communication were measured. RESULTS Among the 2120 patients who died, 222 patients received a continuous infusion of midazolam. A sedation protocol was used in 147 patients, and questionnaires were sent to 124 families. A total of 78 responses were finally returned (proportional, 58 vs. CDS, 20). There were no significant differences in the overall evaluation, family concerns, total score of good death, satisfaction, depression, or balance between symptom relief and maintaining communication. On the other hand, some quality of care items, i.e., relationship with medical staff (P < 0.01), physical care by nurses (P = 0.04), and coordination and consistency (P = 0.04), were significantly better in the CDS group than in the proportional sedation group. Family-reported unfinished business was also better in the CDS group, with marginal significance. CONCLUSIONS Family experience of CDS was not less favorable than proportional sedation, and actually rated more favorably for some elements of quality of care and unfinished business.
Collapse
|
3
|
Robijn L, Deliens L, Rietjens J, Pype P, Chambaere K. Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes. THE GERONTOLOGIST 2020; 60:916-925. [PMID: 31850500 DOI: 10.1093/geront/gnz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved. RESEARCH DESIGN AND METHODS Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach. RESULTS Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available. DISCUSSION AND IMPLICATIONS The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.
Collapse
Affiliation(s)
- Lenzo Robijn
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Judith Rietjens
- Department of Public Health, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands
| | - Peter Pype
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Belgium.,Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| |
Collapse
|
4
|
van Mol MMC, Wagener S, Latour JM, Boelen PA, Spronk PE, den Uil CA, Rietjens JAC. Developing and testing a nurse-led intervention to support bereavement in relatives in the intensive care (BRIC study): a protocol of a pre-post intervention study. BMC Palliat Care 2020; 19:130. [PMID: 32811499 PMCID: PMC7433274 DOI: 10.1186/s12904-020-00636-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND When a patient is approaching death in the intensive care unit (ICU), patients' relatives must make a rapid transition from focusing on their beloved one's recovery to preparation for their unavoidable death. Bereaved relatives may develop complicated grief as a consequence of this burdensome situation; however, little is known about appropriate options in quality care supporting bereaved relatives and the prevalence and predictors of complicated grief in bereaved relatives of deceased ICU patients in the Netherlands. The aim of this study is to develop and implement a multicomponent bereavement support intervention for relatives of deceased ICU patients and to evaluate the effectiveness of this intervention on complicated grief, anxiety, depression and posttraumatic stress in bereaved relatives. METHODS The study will use a cross-sectional pre-post design in a 38-bed ICU in a university hospital in the Netherlands. Cohort 1 includes all reported first and second contact persons of patients who died in the ICU in 2018, which will serve as a pre-intervention baseline measurement. Based on existing policies, facilities and evidence-based practices, a nurse-led intervention will be developed and implemented during the study period. This intervention is expected to use 1) communication strategies, 2) materials to make a keepsake, and 3) a nurse-led follow-up service. Cohort 2, including all bereaved relatives in the ICU from October 2019 until March 2020, will serve as a post-intervention follow-up measurement. Both cohorts will be performed in study samples of 200 relatives per group, all participants will be invited to complete questionnaires measuring complicated grief, anxiety, depression and posttraumatic stress. Differences between the baseline and follow-up measurements will be calculated and adjusted using regression analyses. Exploratory subgroup analyses (e.g., gender, ethnicity, risk profiles, relationship with patient, length of stay) and exploratory dose response analyses will be conducted. DISCUSSION The newly developed intervention has the potential to improve the bereavement process of the relatives of deceased ICU patients. Therefore, symptoms of grief and mental health problems such as depression, anxiety and posttraumatic stress, might decrease. TRIAL REGISTRATION Netherlands Trial Register Registered on 27/07/2019 as NL 7875, www.trialregister.nl.
Collapse
Affiliation(s)
- Margo M. C. van Mol
- Department of Intensive Care Adults, Erasmus MC University Medical Center, P.O. Box 2040, Room Ne409, 3000 CA Rotterdam, the Netherlands
| | - Sebastian Wagener
- Department of Intensive Care Adults, Erasmus MC University Medical Center, P.O. Box 2040, Room Ne409, 3000 CA Rotterdam, the Netherlands
| | - Jos M. Latour
- School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
| | - Paul A. Boelen
- Clinical Psychology Faculty Social Sciences, Arq Psychotrauma Expert Groep, University Utrecht, Utrecht, Netherlands
| | - Peter E. Spronk
- Department of Intensive Care Medicine, ExpIRA - Expertise Center for Intensive Care Rehabilitation Apeldoorn, Gelre Hospitals Apeldoorn, Apeldoorn, The Netherlands
| | - Corstiaan A. den Uil
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Judith A. C. Rietjens
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
5
|
Waller A, Sanson-Fisher R, Nair BR, Evans T. Preferences for End-of-Life Care and Decision Making Among Older and Seriously Ill Inpatients: A Cross-Sectional Study. J Pain Symptom Manage 2020; 59:187-196. [PMID: 31539600 DOI: 10.1016/j.jpainsymman.2019.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/30/2022]
Abstract
CONTEXT Older and seriously ill Australians are often admitted to hospital in the last year of their life. The extent to which these individuals have considered important aspects of end-of-life (EOL) care, including location in which care is provided, goals of care, and involvement of others in decision making, is unclear. OBJECTIVES To determine, in a sample of older and seriously ill Australian inpatients, preferences regarding location in which they receive EOL care and reasons for their choice; who is involved in EOL decisions; disclosure of life expectancy; goals of care; and voluntary-assisted dying. METHODS Cross-sectional face-to-face survey interviews conducted with 186 (80% consent) inpatients in a tertiary referral center aged 80 years and older; or aged 55 years and older with progressive chronic disease(s); or with physician-estimated life expectancy of less than 12 months. RESULTS Home care was preferred (69%), given the perceived availability of family/friends, familiarity of environment, and likelihood of having wishes respected. If unable to make decisions themselves, inpatients wanted family to decide care alone (31%) or with a doctor (49%). Of those who had not discussed life expectancy, 23% wished to. Most (76%) preferred care that maintained quality of life and relieved symptoms. There was some agreement for being sedated at the EOL (63%) and able to access medication to end life (43%). CONCLUSION Most inpatients would prefer EOL care that maintains quality and relieves suffering compared with life extension and to receive this care at home. Family involvement in resolution and documentation of EOL decisions should be prioritized.
Collapse
Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia.
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle and Hunter Medical Research Institute, Callaghan, New South Wales, Australia
| | - Balakrishnan R Nair
- John Hunter Hospital, New Lambton Heights, New South Wales, and the University of Newcastle, Callaghan, New South Wales, Australia
| | - Tiffany Evans
- Clinical Research Design and Statistics Support Unit, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| |
Collapse
|
6
|
Shen HS, Chen SY, Cheung DST, Wang SY, Lee JJ, Lin CC. Differential Family Experience of Palliative Sedation Therapy in Specialized Palliative or Critical Care Units. J Pain Symptom Manage 2018; 55:1531-1539. [PMID: 29474938 DOI: 10.1016/j.jpainsymman.2018.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/08/2018] [Accepted: 02/11/2018] [Indexed: 11/26/2022]
Abstract
CONTEXT No study has examined the varying family experience of palliative sedation therapy (PST) for terminally ill patients in different settings. OBJECTIVES To examine and compare family concerns about PST use and its effect on the grief suffered by terminally ill patients' families in palliative care units (PCUs) or intensive care units (ICUs). METHODS A total of 154 family members of such patients were recruited in Taiwan, of whom 143 completed the study, with 81 from the PCU and 62 from the ICU. Data were collected on their concerns regarding PST during recruitment. Grief levels were assessed at three days and one month after the patient's death with the Texas Revised Inventory of Grief. RESULTS Families' major concern about sedated patients in the PCU was that "there might be other ways to relieve symptoms" (90.2%), whereas families of ICU sedated patients gave the highest ratings to "feeling they still had something more to do" (93.55%), and "the patient's sleeping condition was not dignified" (93.55%). Family members recruited from the ICU tended to experience more grief than those from the PCU (P = 0.005 at Day 3 and < 0.001 at Month 1). PST use predicted higher levels of grief in family members recruited from the PCU (P < 0.001 at Day 3 and Month 1). CONCLUSION Family experiences with the use of PST in terminally ill patients varied in different settings. Supportive care should address family concerns about PST use, and regular attention should be paid to the grief of individuals at higher risk.
Collapse
Affiliation(s)
- Hui-Shan Shen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Szu-Yin Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Respiratory Care Center, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Denise Shuk Ting Cheung
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Shu-Yi Wang
- Loretto Heights School of Nursing, Regis University, Denver, Colorado, USA
| | - Jung Jae Lee
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong; Alice Ho Miu Ling Nethersole Charity Foundation Professor in Nursing, Hong Kong.
| |
Collapse
|
7
|
A systematic literature review on the ethics of palliative sedation: an update (2016). Curr Opin Support Palliat Care 2016; 10:201-7. [DOI: 10.1097/spc.0000000000000224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|