Continuous Deep Sedation at the End of Life of Children in Flanders, Belgium

Abstract

Context Few guidelines have yet been put forth for continuous deep sedation in pediatrics, and empirical data on the use of this practice in minors are rare. Objectives To estimate the incidence of continuous deep sedation in minor patients (aged 1–17) and describe the characteristics of, and the decision-making process before, continuous deep sedation. Methods An anonymous population-based postmortem survey was mailed to all physicians signing the death certificates of all patients aged 1–17 years who died between June 2007 and November 2008 in Flanders, Belgium. The questionnaire concerned whether or not continuous deep sedation was used at the end of life and measured characteristics of sedation and the decision-making process preceding it. Results Response rate was 70.5% ( n = 165). Of all children, 21.8% had been continuously and deeply sedated at the end of life. Duration of sedation was one week or less in 72.4% of cases, and artificial nutrition and hydration were administered until death in 54.3% of cases. Benzodiazepines were used as the sole drug for sedation in 19.4% of cases, benzodiazepines combined with morphine in 50%, and morphine as the sole drug in 25%. In 23.5% of cases, physicians had the explicit intention, or the concurrent intention, to hasten death. Only 3.0% of patients requested sedation and 6.1% consented. Parents consented in 77.8% of cases and requested sedation in 16.7%. Conclusion Minor patients were commonly kept in continuous deep sedation or coma until death in Flanders, Belgium. Given the high incidence of the practice and indications that it is often used without involving the patient—and sometimes with a life-shortening intention—the development of specific guidelines for sedation in children might contribute to due care practice.