Last Days Of Life Research Articles

Personalized delirium sedation goal (PDSG): Balancing comfort and communication in the last days of life.

12033 Background: Management of patients with agitated terminal delirium is challenging as clinicians try to find a balance between adequate sedation to maximize comfort while retaining communication abilities. A novel approach to tailor care is to ask caregivers for a PDSG by setting an individualized target for sedation. In this study, we examined PDSG using (1) clinical vignettes and (2) as a clinical response criteria in patients enrolled onto a randomized clinical trial. Methods: This is a pre-planned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated terminal delirium refractory to low dose haloperidol (clinicaltrials.gov: NCT03021486; Lancet Oncol 2020 21:7 989-998). At baseline, caregivers and bedside nurses were independently asked to select the PDSG for 6 patient vignettes that differed by level of agitation (high vs. moderate), ability to communicate (yes or no), and survival (days vs. weeks). There were 5 choices for PDSG, corresponding to RASS scores of 0 (no sedation), -1 to -2, -3, -4 and -5 (deep sedation). Respondents were also asked to select the PDSG for the enrolled study patient, which were assessed against actual RASS scores over the first 24 hours to determine a response. We examined the association between PDSG levels and various patient and respondent characteristics with multi-level cumulative logits models. Results: 68 patients were enrolled and 45 received the masked study interventions (median survival 73 h [95% CI 49,106 h]). 42 caregivers and 40 nurses provided PDSG data. For the case vignettes, 7-31% of caregivers and 20-55% of nurses chose RASS -4 or -5 as PDSG. PDSG was significantly lower for patients who were unable to communicate (odds ratio [OR] 3.1-4.4, P < 0.0001), patients with only days of survival vs. weeks (OR 1.7, 95% confidence interval [CI] 1.2-2.5; P = 0.002) and if the respondent was a bedside nurse (OR = 2.5, 95% CI 1.8-3.6; P < 0.0001). For study patients, 12 (29%) of caregivers and 13 (33%) of nurses selected RASS -4 or -5 as PDSG. After the first 2 hours, 40-61% of patients achieved RASS scores that were within ±1 point of caregiver’s PDSG, with no significant difference detected among treatment groups (P = 0.45). PDSG for study patients was significantly lower if the respondent perceived severe distress related to agitation (OR = 4.4, 95% CI 1.1-17.2; P = 0.03), particularly if the respondent was a bedside nurse (OR = 4.8, 95% CI 1.4-16.2; P = 0.01). Conclusions: PDSG represents a novel response criterion to tailor care for patients with agitated terminal delirium. Lighter sedation was preferred by caregivers compared to nurses, particularly for patients with less agitation, ability to communicate, and longer expected survival. These findings may allow clinicians to better tailor the level of sedation for patients with restlessness/agitation in the last days of life. Clinical trial information: NCT03021486.

Chemotherapy use at the end of life in Brazil.

e24003 Background: Chemotherapy in the last days of life is not associated with a survival benefit, and recent data suggest it may cause harm by decreasing quality of life and increasing costs. Both ESMO and ASCO have published position statements encouraging discussions about the appropriate cessation of chemotherapy. End-of-life chemotherapy rates vary worldwide but in summary, up to a fifth of cancer patients are treated with chemotherapy in the last month of life with no clear benefits. The aim of this study is to describe the rate of chemotherapy use in the last month of life in patients who are candidates for palliative care in Brazil. Methods: It is a prospective non-concurrent cohort carried out from a database developed through probabilistic and deterministic linkage of data from information systems of the Brazilian Public Health System. The study population is composed of all patients who started cancer treatment between 2009 and 2014 and who was hospitalized at least 1 time after starting treatment. To address the indication for palliative care, patients whose death occurred within one year after the first hospitalization were selected. Results: A total of 299,202 patients started cancer treatment in that period and 62,249 died 1year after hospitalization. Among the deceased patients, the median age was 62 years, 50.9% of them were in stage IV and 34.1% in stage III and 46% lived in the southeastern region of the country. The most common cancers were lung (n = 17805; 28.6%) colorectal (n = 12273; 19.7%) and gastric (n = 10248; 16.5%). The average number of hospitalizations was 2.7 and 89% of these patients required emergency hospitalization. About half (45,4%; n=28,250) of the patients underwent chemotherapy at the last 30 days of life. The rates of use of chemotherapy in the last month was 44% for lung cancer, 74,4% for colon, 50.2% for gastric and 51.8% breast cancers. Conclusions: Despite international recommendations on the use of chemotherapy at the end of life, this seems to be a common practice unfortunately. Measures to implement early palliative care should be a priority for the care of cancer patients in Brazil.

High flow nasal therapy in the management of hypoxemic dyspnea at the end of life

Refractory dyspnea is challenging for physicians treating patients near to the end of life. High-flow nasal therapy (HFNT). We report a case in which HFNS was effective in a patient in the last days of life to mitigate dyspnea allowing a minimal quality of life for some days before dying. HFNT may be helpful for severely hypoxemic patients who are unresponsive to common measured adopted in the last weeks–days of life of advanced cancer patients. Future studies should assess an early use of this device in combination with lower doses of opioids or as an alternative.

Lung cancer

Lung cancer is the most common cause of cancer-related death in men, and the second most common one in women. The primary cause remains tobacco smoking, but there is an ongoing association with air pollution and specific carcinogens including radon, asbestos and coal fumes. The outcomes remain poor with fewer than one-in-five patients surviving 5 years after diagnosis. Lung cancer presents in several different ways; early recognition and diagnosis is essential to improve outcomes. Much of the work in general practice with patients who are suffering from lung cancer involves palliative care, and by managing patients well, GPs can have a big impact on patients’ last days of life.

Medication use and deprescribing in older patients in the last 14 days of life

Abstract Introduction Older patients may continue to receive potential inappropriate medications (PIMs) at the end of life. Application of consensus-based tools to identify PIMs may result in the identification of candidate medications for deprescribing, with the aim of overcoming the harm of inappropriate medication and improving clinical outcomes. This study aims to describe medication use and deprescribing patterns, and to assess prescribing appropriateness for older people in the last 14 days of life in the hospice setting. Methods Longitudinal, retrospective cohort study of deceased patients (≥65 years) who died between 1 January 2018 and 31 December 2018 in three hospices in a region of the United Kingdom. We identified prescribed and deprescribed medications and assessed medication appropriateness using consensus-based criteria, namely STOPPFrail[1] and criteria developed by Morin et al.[2] Unexpected/sudden deaths were excluded. Statistical analysis was conducted using SPSS statistics 26.0. Preliminary results Data collection is currently ongoing. To date, data from 69 deceased patients have been collected (mean age 76.1 years). Of these decedents, 62.3% were female and the majority (just under 90%) had cancer reported as the cause of death. During the last 14 days of life, each patient was prescribed a mean of 17 ± 5 different medications. The mean number of medications decreased significantly between day 14 and the day of death from 13.2 ± 4.4 to 9.4 ± 3.7 (P < 0.01). Six hundred and thirty-nine medications were discontinued, with just under 70% stopped in the last seven days before death. 34.9% of those discontinued were prescribed for chronic conditions and 22% were proton pump inhibitors. In most decedents, swallowing difficulty was the reason for medication discontinuation. According to the STOPPFrail criteria [1], 42 (60.1%) of decedents received at least one PIM between day 14 and the day of death. There were 59 PIMs in total for these patients; of these 20.3% were hyoscine butyl-bromide and 16.9% were gliclazide. Using the criteria developed by Morin et al [2], 103 medications were assessed as being of questionable (81.6%) or inadequate (18.4%) clinical benefit. Of these, 64.1% were initiated during hospice admission. There was a statistically significant association between medications of questionable clinical benefit and medication number during the last 14 days of life (P < 0.01). Three of the PIMs were vitamins, considered inappropriate by both sets of criteria. Prescribing of PIMs reduced as patients neared death. Conclusion A substantial proportion of older patients with life-limiting diseases receive PIMs during their last days of life. No systematic discontinuation of inappropriate medications was observed thus guidelines and resources are needed to facilitate rationalisation and deprescribing of drug treatments for older patients in the last days of life. The small sample size makes the relationship between most variables insignificant; however, data extraction is still ongoing in hospices.

Palliative Care Home Support Packages (PEACH): a carer cross-sectional survey

BackgroundIn December 2013, a partnership between five local health districts and a non-governmental organisation implemented the Palliative Care Home Support Packages (PEACH) Program. The PEACH Program aims to support palliative...

Interprofessional End-of-Life Simulation in Nursing Education

Many students report that they do not have the opportunity to provide end-of-life care before completing their undergraduate nursing degree. High fidelity simulation may prepare both graduate and undergraduate students to collaborate when caring for patients in their last days of life and give them opportunities to explore their own beliefs, perceptions, and feelings related to death and dying. This article provides a brief overview of how one nursing program used simulation to bring prelicensure and graduate family nurse practitioner students together along with campus ministry to successfully deliver collaborative care. This innovative simulation exercise helped students and professionals develop shared goals and promoted communication when providing physical and spiritual care to end-of-life patients.

Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life.

While transfer of aged care facility (ACF) residents to an acute hospital is sometimes necessary, for those at end of life this can cause fragmented care and disruption. To explore the characteristics of ACF residents transferred to hospital in the last 24 h of life and factors that might influence this decision, including access to medical review, advance care planning (ACP) and pre-emptive symptom management prescribing, an area not previously researched. A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 and 2017 who died within 24 h of transfer. A total of 149 patients met the criteria. The median age was 87 years, and 63 (42%) were male. Eighty-three (56%) were transferred 'out-of-hours', the majority (71%) having no medical review in the 24 h prior, and 43 (29%) died within 4 h of arrival. The most common reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and the most common cause of death was pneumonia (37%). Some form of ACP documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7 (8%) had this pre-emptively prescribed on their ACF medication chart. Appropriate decision-making around hospital transfers and end-of-life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. ACP is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end-of-life care needs of this cohort.

Barriers to end-of-life care delivery to home-dwelling terminally-ill older patients: A qualitative content analysis

Background: In the last days of life, home-dwelling terminally-ill older patients have complex care needs. End-of-life (EOL) care for these patients is usually delivered at home. However, there is limited information about the barriers to EOL care delivery to home-dwelling terminally-ill older patients. Objectives: This study is aimed to explore the barriers to EOL care delivery to home-dwelling terminally-ill older patients. Methods: This qualitative study was conducted in 2017–2018. Ten family caregivers and ten health-care providers were purposively selected. The main inclusion criterion was the experience of EOL care delivery to home-dwelling terminally-ill older patients. Data were collected through semi-structured interviews and were analyzed through conventional content analysis. In total, 23 interviews were held with twenty participants. Results: The barriers to EOL care delivery to home-dwelling terminally-ill older patients were categorized into the following three main categories and ten subcategories: inappropriate community-based healthcare context (subcategories: lack of public home care services, lack of palliative/hospice care services, legal/ethical dilemmas, and wrong cultural beliefs leading to wrong EOL care), unsupportive healthcare providers (subcategories: limited preparation for EOL care delivery, negligence towards appropriate home care delivery, and indifference to patients' and their families' rights), and inappropriate family conditions (subcategories: families' lack of care-related knowledge and skills, families' poor financial status, and tension in families). Conclusion: There are different familial, financial, professional, organizational, and social barriers to EOL care delivery to home-dwelling terminally-ill older patients. Culturally-appropriate policies and strategies are needed for operationalizing EOL care, integrating it into the public health-care system, and preparing healthcare providers and family caregivers for its delivery.

Changing the Care Paradigm for Patients: Advanced Illness Beds Care Model.

Over 90 million Americans suffer from advanced illness (AI) and spend their last days of life in critical care units receiving costly, unwanted, aggressive medical care. Evaluate the impact of a specialized care model in medical/surgical units for hospitalized geriatric patients and patients with complex care requirements where designated AI beds align care with patient's wishes/goals, minimize aggressive interventions, and influence efficient resource utilization. US based multi-facility retrospective, longitudinal descriptive study of screened positive AI patients in AI Beds (N = 1,237) from 3 facilities from 2015 to 2017. Patient outcomes included 60% referrals to AI beds from ICU, a decrease of 39-49% in average ICU LOS, a 23% reduction of AI bed patient expirations, 9.0% referrals to hospice, and projected cost savings of $4,361.66/patient, US dollars. Allocating AI beds to deliver care to AI patients resulted in a decreased cost of care by reducing overall hospital LOS, mortality, and efficient use of both critical care and hospital resources.

Palliative Sedation at the End of Life: A Comparative Study of Chronic Obstructive Pulmonary Disease and Lung Cancer Patients

Background: Although patients with chronic obstructive pulmonary disease (COPD) receive poor-quality palliative care, information about the use of palliative sedation (PS) in the last days of life is very scarce. Objectives: To compare the use of PS in hospitalized patients who died from COPD or lung cancer and identify factors correlating with PS application. Methods: In a retrospective observational cohort study, from 1,675 patients died at a teaching hospital between 2013 and 2015, 109 patients who died from COPD and 85 from lung cancer were compared. Sociodemographic data, clinical characteristics, health care resource utilization, application of PS and prescribed drugs were recorded. Results: In the last 6 months of life, patients who died from COPD had more hospital admissions due to respiratory causes and less frequent support by a palliative home care team (PHCT). Meanwhile, during their last hospitalization, patients who died from COPD had fewer do-not-resuscitate orders and were subjected to more intensive care unit admissions and cardiopulmonary resuscitation maneuvers. PS was applied less frequently in patients who died from COPD than in those who died from lung cancer (31 vs. 53%, p = 0.002). Overall, previous use of opioid drugs, support by a PHCT, and a diagnosis of COPD (adjusted odds ratio 0.48, 95% CI: 0.26–0.89, p = 0.020) were retained as factors independently related to PS. In COPD patients, only previous use of opioid drugs was identified as a PS-related factor. Conclusion: During their last days of life, hospitalized COPD patients receive PS less frequently than patients with lung cancer.

M. M. Prishvin and N. A. Semashko: literary image of the “gymnasium friend” in works of the writer

The subject of this article is the analysis of the history of relations between M. M. Prishvin and N. A. Semashko since gymnasium childhood until the last days of life. It is demonstrated that if the biographical material on enduring friendship between Prishvin and Semashko, contained in reminiscences of their contemporaries and works of the writer himself, is given considerable attention, then his diary notes, which significantly transform the representations on true nature of their relations, have not yet become the subject of research. The article employs the method of historical reconstruction of ideological-political context of life of the Soviet society, which gives a better perspective on the peculiarities of artistic interpretation by M. M. Prishvin of the party and state activity of N. A. Semashko. The novelty of this article consists in introduction into the scientific discourse of the new facts from Prishvin’s Diary that consisted of 18 volumes and was published only in post-Soviet time  (1991-2017), which is a testimony that his relations with the People's Commissar of Public Health N, A, Semashko were often tainted with irreconcilable ideological and worldview discrepancies. It is no coincidence that in his autobiographical novel “The Chain of Kashchei”, Prishvin portrayed Semashko not only as an ideological supporter of Leninism, but also a nihilist-Nietzschean Yefim Nesgovorov. Morveover, the history of relations with Semashko sheds light on the reasons of Prishvin's disappointment with the revolutionary ideology of Bolshevism.

The last 48 hours

The last days of life are challenging for both patients and their loved ones. Recognition of the terminal stage of life can allow time for care planning. An early discussion can provide an opportunity for questions. It can be reassuring for patients and families to know that care needs are being carefully considered and met at this important time. The management of physiological changes, psychological distress, and spiritual needs at the end of life can improve quality of care and the quality of death; a ‘good death’ can help the bereavement and wellbeing of those left behind.

Abordagem da enfermagem nos cuidados paliativos oncológicos em tempos de pandemia do covid-19: revisão narrativa para contribuição científica

Realizar uma revisão bibliográfica analisando o poder de decisão do paciente oncológico que, em leito de terapia intensiva, em um cenário de pandemia do novo coronavirus com a importância da preservação das faculdades mentais plenas ou parciais nos últimos dias de vida, manifesta se interesse por descontinuar o tratamento em leito de UTI pela possibilidade eminente de mais um agravante do contagio do covid-19 (coronavirus). O presente conteúdo científico e narrativo reverencia a atuação da assistência multiprofissional dentro do atual contexto da humanização de um paciente dependente de outros, por considerar os últimos desejos quanto conscientes, não restringindo se somente aos procedimentos clínicos oncológicos. Espera se que através deste conteúdo, os profissionais de enfermagem possam ter maior aprimoramento na atuação holística do paciente oncológico, bem como na capacitação de orientar seus familiares e amigos a desenvolver abordagem confortantes ao mesmo em período de isolamento social. Observou-se que através desta investigação pode se traçar um cenário muito importante no que tange a abordagem a esta referida clientela em fase terminal, ressaltando as recentes mudanças na assistência em Unidades de Terapia Intensiva, oncologia e novas perspectivas da terapêutica do novo covid-19.

End of Life Healthcare and Hospice Utilization Among Patients with Diffuse Large B-Cell Lymphoma

Introduction: Although diffuse large B-cell lymphoma (DLBCL) is considered a highly curable malignancy, 5-year overall survival rates have ranged between 60-65% in population-based studies. There is a lack of data on predictive factors that can guide therapy in DLBCL in the frontline setting or at relapse. Therefore, most patients are treated in a similar fashion with the goal of achieving cure, which may lead to increased times spent in the healthcare setting and decreased rates of hospice enrollment toward the end of life in DLBCL patients. In this study, we sought to examine the patterns of healthcare and hospice utilization in the last 90 days of life among DLBCL patients. Methods: We conducted a retrospective analysis using a registry of DLBCL patients who died between 2009 and 2020 from a single-center. We quantified the total time spent in the last 90 days in a medical setting, amassing time spent in the emergency ward, inpatient wards, oncology clinics, infusions, and transfusions. We computed each patient's round trip time to and from the clinic, and used pre-specified standardized appointment times to one hour for clinic visit and two hours for infusion/transfusion visits. Hospital days were counted as 24 hour periods. We combined the total time spent with healthcare and reported it as a percentage of last 90 days of a patient's life. Additionally, we captured other metrics such as time from diagnosis to death, percentage of ICU admissions, and hospice enrollment. We conducted univariate and multivariate analyses using age, stage, International Prognostic Index (IPI score), sex, insurance status, double/triple hit status to ascertain factors associated with increased hospitalizations (≥15 days), hospice enrollment, and short interval from hospice enrollment to death (≤5 days). Results: A total of 83 patients were included in the study. The median age at diagnosis was 64 years, and 47% were males. Median IPI score was 3, and 14/53 (28%) were patients with high grade lymphomas (double/triple hit). Median time from diagnosis to death was 9 months, and 77% patients died during or shortly after completion of first line therapy. The proportion of time spent by patients with inpatient or outpatient healthcare in the entire cohort during their last 90 days of life was 23%. The patients spent 16% of their last 90 days in the hospital (median 14 days, interquartile range or IQR 7-26). The median number of electronic portal messages or calls to the oncology clinic was 3 (IQR 0-5). 54% patients were enrolled in hospice within the last 90 days, with a median interval from hospice enrollment to death of 5 days. Overall, 54% of the 83 patients died in the hospital itself, and this comprised 84% of deaths among patients who were not enrolled on hospice. Also, 56% percent of the patients had at least one intensive care unit (ICU) admission in their last 90 days of life. On univariate analysis, the only factor associated with ≥15 days hospitalization was increasing age (p=0.013), while no significant associations were found on multivariate analysis for this outcome measure. Higher IPI score was found to be positively correlated with enrollment on hospice [RR 2.7; 95% CI 1.38-5.45]. No factors were found to be significantly predictive of a short interval from hospice enrollment to death (≤5 days) on univariate or multivariate analysis. Conclusion: In our study, DLBCL patient spent 23% of their last 90 days of life with healthcare services, which predominantly included hospital stays. While utilization of hospice was slightly over 50%, most patients were on hospice for less than one week before death. Over half the patients had at least one ICU admission during last 90 days of life. Chemotherapy use was prevalent in the last days of life, with 7% of patients having received greater than 2 cycles of therapy within the last 30 days of life. Advanced IPI was associated with increased enrollment on hospice. Our study shows high burden of healthcare utilization in DLBCL patients, with most deaths occurring in the hospital. There is a need to develop strategies to optimize utilization of hospice services, which may include earlier goals of care discussion and palliative care referrals. Even in a highly curable malignancy such as DLBCL, our study highlights an area of unmet need to improve patient/caregiver experience toward end of life. Disclosures No relevant conflicts of interest to declare.

Artificial intelligence and palliative care: opportunities and limitations.

The so-called artificial intelligence tools applied to palliative care (machine learning, natural language processing) have great potential to support clinicians in improving decision-making processes and in identifying those who are at high risk of mortality or at greater risk of inappropriate treatment and/or non-positive outcomes. The improvement of prognostic abilities may help to avoid that some choices of patients with serious diseases are taken only in the last days of life, in the face of treatment options not previously discussed in an adequate and shared way. These tools can facilitate some essential aspects in the practice of palliative care, for example the activation of interviews that have as their objective the advance care planning and the definition of treatments consistent with the needs and desires of patients, especially in final stages of life. The development, also in our country, of projects for the application of artificial intelligence in palliative care requires particular attention to the possible organizational repercussions and to some ethical and relational aspects. It will be necessary to reflect on the most appropriate organizational models and on the specialized resources necessary in relation to the foreseeable increase in the number and variability of patients with early identified palliative care needs. These tools must not interfere in fundamental elements of the relationship between patient and doctor, that is the ability to communicate a poor prognosis in an individualized and ethically appropriate way.

Palliative care needs and utilisation of different specialist services in the last days of life for people with lung cancer.

To (a) compare palliative care needs of lung cancer patients on their final admission to community-based and inpatient palliative care services; and (b) explore whether and how these care needs affect their utilisation of different palliative care services in the last days of life. Descriptive study involving 17,816 lung cancer patients who received the last episode of palliative care from specialist services and died between 1 January 2013 and 31 December 2018. Both groups of patients admitted to community-based and inpatient palliative care services generally experienced relatively low levels of symptom distress, but high levels of functional impairment and dependency. "Unstable" versus "stable" palliative care phase (Odds ratio=11.66; 95% Confidence Interval: 9.55-14.24), poorer functional outcomes and severe levels of distress from many symptoms predicted greater likelihood of use of inpatient versus community-based palliative care. Most inpatient palliative care admissions are not associated with high levels of symptom severity. To extend the period of home care and rate of home death for people with lung cancer, additional investment is required to improve their access to sufficiently skilled palliative care staff, multi-disciplinary teams and 24-hour home support in community settings.

Reducing Results Variance in Lifespan Machines: An Analysis of the Influence of Vibrotaxis on Wild-Type Caenorhabditis elegans for the Death Criterion.

Nowadays, various artificial vision-based machines automate the lifespan assays of C. elegans. These automated machines present wider variability in results than manual assays because in the latter worms can be poked one by one to determine whether they are alive or not. Lifespan machines normally use a “dead or alive criterion” based on nematode position or pose changes, without poking worms. However, worms barely move on their last days of life, even though they are still alive. Therefore, a long monitoring period is necessary to observe motility in order to guarantee worms are actually dead, or a stimulus to prompt worm movement is required to reduce the lifespan variability measure. Here, a new automated vibrotaxis-based method for lifespan machines is proposed as a solution to prompt a motion response in all worms cultured on standard Petri plates in order to better distinguish between live and dead individuals. This simple automated method allows the stimulation of all animals through the whole plate at the same time and intensity, increasing the experiment throughput. The experimental results exhibited improved live-worm detection using this method, and most live nematodes (>93%) reacted to the vibration stimulus. This method increased machine sensitivity by decreasing results variance by approximately one half (from individual error per plate to ) and error in lifespan curve was reduced as well (from to ).

Semantics of the verbs with the middle degree of polysemy denoting conflict actions in modern English

Linguists around the world hold the opinion that nowadays lexical semantics is the most productive basis for all-round studying linguistic content without which the definite language system can’t be adequately presented in general. Semantics is defined as the study of words and their meanings. The growing interest to the study of the language units in the semantically united group can be explained by the fact that only carefully collected and classified language material allows to solve a range of the most important issues. That is why the present article deals with the study of the group of verbs with the middle degree of polysemy denoting conflict actions which occupy a significant place in the system of the English language. Conflict actions are classified by types and forms of expression, but most clearly their versatility is revealed through their formalized research. By means of the formalized lexical semanticsʼ analysis methodology their qualitative and quantitative characteristics have been disclosed. Besides, both common and distinctive features of the units’ semantics under study have been revealed. On this basis lexical semantics of the verbs denoting conflict actions as well as their seme stock in modern English have been highlighted. The semantic analysis of the verbs with the middle degree of polysemy denoting conflict actions in modern English gives reason to consider the lexis fragment under study as a definite semantic structure, the elements of which are placed hierarchically in their various relationships with both each other and other words. In its turn, the conflict actions based on the opposing goals, interests, types of people’s behavior and social groups, accompanied by negative psychological manifestations, are worth studying from psychological, sociological and linguistic aspects. In addition, it is no secret that conflict actions are constant “fellows” of man which accompany a person from the first until the last day of life. Life comprises “everlasting” problems between leader and subordinates, common habitation of people of various characters, interests and views on life. Thus, at this level conflict actions arise that confront us with such phenomena as terror, strike, war, controversy etc. In the process of our complex lexico-semantic analysis, we have found common (to make (smth.) against smb.; to contend in, for, with or against smth./smb.; violently; side by side with; to oppose (in smth.); rebelliously; to oppose by contrary operations; to fight for, against; to meet in combat; to engage in battle; to strike; to put an end to; to strive in, with or against smb. or smth.; to throw, to combat, etc.) and distinctive (to break up with smb.; to expose; to urge, to close, to repulse by force of arms; to follow a person or thing; to comply with, to continue; to load or burden with smth.; to tyrannize over, etc.) features of the lexical units in question.Keywords: lexical semantics, conflict actions, formalized analysis, seme stock, qualitative and quantitative characteristics.

Continuous Deep Sedation is Not Associated with Shorter Survival in the Last Days of Life in Patients with Advanced Cancer: A Propensity Score-Weighted Analysis of a Prospective Cohort Study

Background: Continuous deep sedation (CDS) is ethically controversial with respect to whether it shortens a patient’s life. Previous studies reported no significant difference in survival from admission or enrolment into a palliative care program to death between patients treated with and without CDS. However, these baselines are too distant from the initiation of CDS to detect the effect of CDS on survival. We aimed to examine whether CDS shortens patient survival from the day of Palliative Performance Scale decline to 20 (PPS20). Methods: This study was a part of a multicenter prospective cohort study that recruited patients between Jan. and Dec. 2017 in Japan (EASED study). Consecutive Adult patients with advanced cancer admitted to 23 participating inpatient palliative care units were eligible for this analysis. We compared survival from PPS20 between those who did and did not receive CDS. We used the inverse probability of treatment weighting method to control for potential confounders of patient characteristics, complications and laboratory data at admission, and symptoms at PPS20. Findings: A total of 1926 patients were enrolled. Of these, patients discharged alive were excluded, and finally we analyzed 1625 patients of whom 156 (9.6%) received CDS. Median survival from PPS20 of 1625 patients was 3.4 days (95% CI: 3.2-3.7). CDS was not associated with a significant survival risk from PPS20 (adjusted hazard ratio: 1.06, 95% CI:0.85–1.33; p = 0.595). In exploratory subgroup analyses, a significant survival risk was not observed in any subgroup except for those with primary lung cancer and agitated delirium. Interpretation: CDS was not associated with shorter survival in the last days of life in patients with advanced cancer, and CDS had no measurable effects on survival. Our findings may relieve the concern of patients, families, and physicians that CDS might shorten survival. Funding Statement: This work was supported by Grant-in-Aid from the Japanese Hospice Palliative Care Foundation and in part by JSPS KAKENHI Grant number JP19H03869. Declaration of Interests: No relevant conflict of interest to declare. Ethics Approval Statement: This study was conducted in accordance with the ethical standards of the Helsinki Declaration and the ethical guidelines for epidemiologic research of the Ministry of Health, Labour and Welfare of Japan. The local institutional review boards of all participating institutions approved this study. Japanese law does not require individual informed consent from participants in a non-invasive observational trial such as this. Therefore, we used an opt-out method rather than acquiring written or oral informed consent.