Palliative Sedation Research Articles

Pulmonologists' experiences with palliative sedation for terminally ill patients.

Legeforeningen har utarbeidd retningslinjer for lindrande sedering i livets sluttfase, sist revidert i 2014. Vi ville undersøke lungelegar sin kjennskap til retningslinjene og bruk av lindrande sedering ved lungesjukdomar. Eit elektronisk spørjeskjema blei sendt til alle medlemmer av Norsk forening for lungemedisin (529 legar) i oktober 2022. Svara blei analysert med deskriptiv statistikk, og fritekstkommentarane blei analysert ved systematisk tekstkondensering. Totalt 50 legar svarte (9,5%). 22 hadde kjennskap til retningslinjene, og eit mindretal meinte desse var tydelege og gav god støtte. 37 oppgav at lindrande sedering blei gjennomført der dei jobba, men det var stor variasjon i kor ofte. 25 av deltakarane hadde vore med på å gjennomføre lindrande sedering ein eller fleire gonger, og 19 hadde opplevd etiske utfordringar relatert til dette. Sederinga vart oftast utført hjå pasientar med lungekreft ved intraktabel dyspné og smerter, men også hjå andre sjukdomsgrupper. Avgjerda vart stort sett tatt i tverrfagleg fellesskap, og fritekstkommentarane utdjupa at dette gav støtte og tryggleik. Det vart påpeikt ein krevjande grenseoppgang mot dødshjelp, og ønskje om at gråsonene kunne utdjupast meir i retningslinjene. Definisjonen av lindrande sedering blir framleis oppfatta ulikt og kan framstå uklar. Det kan moglegvis vere til hjelp å legge til diagnosespesifikke råd ved revisjon av gjeldande retningslinjer.

Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

New recommendations on palliative sedation

Palliative sedation aims to relieve refractory suffering in patients with life-limiting disease. The 2009 framework on palliative sedation of the European Association for Palliative Care (EAPC) has recently been updated. Recommendations have also been formulated by the research group SedPall in Germany. This article describes the social and ethical complexity of decision-making and summarises the recommendations. Patient autonomy is emphasised. Refractoriness of the suffering should be determined jointly by physician and patient. Sedation should be proportional, that is to say, its form and duration should be adapted to the patient's individual situation. The decision on palliative sedation and that on hydration involve two separate decision-making processes. Midazolam should be used as first choice. Particular attention should be paid to the patient's relatives/significant others and the treating team.

Early deep-to-light sedation versus continuous light sedation for ICU patients with mechanical ventilation: A cohort study

BackgroundSedation strategies have not been well established for patients being treated with invasive mechanical ventilation (MV). This study aimed to compare the potential effects of alternative sedation strategies – including early deep-to-light sedation (DTLS), continuous deep sedation (CDS) and continuous light sedation (CLS, the currently recommended strategy) – on ventilator, intensive care unit (ICU) or hospital mortality. MethodsA cohort study was conducted using two large validated ICU databases, including the Registry of Healthcare-associated Infections in ICUs in China (ICU-HAI) and the Medical Information Mart for Intensive Care (MIMIC). Patients who received MV for more than 3 days with one of three sedation strategies were included. Multivariable survival analyses with inverse probability-weighted competing risk models were conducted separately for ICU-HAI and MIMIC cohorts. Adjusted estimates were pooled using fixed-effects models. ResultsIn total, 6700 patients (2627 ICU-HAI, 4073 MIMIC) were included in the cohort study, of whom 2689 received CLS, 2079 CDS and 1932 DTLS. Compared to CLS, DTLS was associated with lower ICU mortality (9.3% vs. 11.0%; pooled adjusted HR 0.78, 95% CI 0.66−0.94) and hospital mortality (16.0% vs. 14.1%; 0.86, CI 0.74–1.00); and CDS was associated with higher ventilator mortality (32.8% vs. 7.0%; 4.65, 3.91–5.53), ICU mortality (40.6% vs. 11.0%; 3.39, 2.95–3.90) and hospital mortality (46.8% vs. 14.1%; 3.27, 2.89–3.71) than CLS. All HRs were qualitatively consistent in both cohorts. ConclusionsCompared to the continuous light sedation, early deep-to-light sedation strategy was associated with improved patient outcomes, and continuous deep sedation was confirmed with poorer patient outcomes.

Palliative Care for Patients With Breast Cancer in a Palliative Care Unit of a Japanese Hospital.

Background This study describes the end-of-life care management in palliative care units (PCUs) for patients with breast cancer in Japan. Methods The medical data of patients admitted to the palliative care unit of Kashiwara Municipal Hospital between October 2017 and December 2023 were analyzed. A chi-square test was conducted to analyze the data using the Excel software (Microsoft Corp., Redmond, WA). Results The most common clinical condition among the 32 patients with breast cancer in our palliative care unit was pleural effusion (17/32, 53.1%), followed by obstructive jaundice (6/32, 18.8%), disseminated intravascular coagulation (DIC) (4/32, 12.5%), and hypercalcemia (1/32, 3.1%). Most patients had no indications for pleural effusion removal, biliary drainage, or anticoagulation therapy. Palliative sedation was performed in 25% of the patients with breast cancer, mainly to relieve intolerable general fatigue. There were no statistically significant differences in the sedation ratios between breast cancer and cancers at other primary sites. Conclusion Palliative treatments using appropriate infusion, narcotics, oxygen administration, various drugs, and sedation were administered in our palliative care unit to relieve symptoms instead of radical treatments for severe clinical conditions of breast cancer.

Exploring the grief journey of bereaved spouses: Insights into the impact of sedation within palliative care

ABSTRACT Despite being the most susceptible to psychopathological consequences, bereaved cancer spouses remain a vastly understudied group. Addressing this gap, a dedicated French research team comprising clinical psychologists, philosophers, and physicians is conducting an ongoing study focused on the emotional and affective complexities experienced by bereaved spouses after the loss of a loved one due to oncological diseases within the realm of palliative care and Continuous Deep Sedation until Death (CDSD). The preliminary data presented below concern the analysis of nine semi-directed interviews analyzed using ALCESTE software, a tool for statistical analysis of textual data based on word co-occurrences. Analysis and comparison of the thematic categories that emerged showed that social support, deep loneliness, and the preservation of memories emerged as central elements of the marital bereavement experience. In addition, the study highlights the critical role of comprehensive palliative care in France and the delicate nature of sedation experiences, revealing intense emotions such as helplessness and anger. Clear communication and active family participation in end-of-life decisions emerged as crucial factors in alleviating the grieving process in spouses. These findings provide valuable insights for healthcare professionals and counselors and underscore the critical need for further research focused on sedation.

The Attitudes and Experiences of Hospice Nurses Regarding Palliative Sedation: A Cross-Sectional Descriptive Study.

Background: Despite the global acceptance of palliative sedation, China's engagement in this field remains comparatively restricted. There exists a scarcity of information regarding the attitudes and experiences of hospice nurses concerning palliative sedation. Objectives: This survey aimed at investigating the attitudes of Chinese hospice nurses toward palliative sedation, as well as their practices in palliative sedation. Design: A cross-sectional descriptive study. Setting/Subjects: In 2023, the survey on palliative sedation was introduced during the opening ceremony of the largest National Symposium on New Advances in Hospice Nursing in China. Subsequently, the study questionnaire was disseminated through email to a cohort of 806 hospice nurses attending the conference. Measurements/Results: The statistical analysis was based on 641 valid responses. Among them, 508 had no experience with palliative sedation, while only 133 had such experience. Around 92.5% of hospice nurses with experience in palliative sedation agreed with the physician's instructions to begin palliative sedation. Nurses were present at the start of sedation in nearly all cases (97.0%), and most doctors (79.7%) and family members (82.0%) were also present. However, 8.3% of them perceived that there was no difference between palliative sedation and euthanasia. Furthermore, 13.5% of participants believed that the purpose of palliative sedation was to hasten death. Conclusions: Hospice nurses play a crucial role in the process of palliative sedation, yet they also face significant challenges. It suggests that there is an urgent need in China for the development of consensus or guidelines for palliative sedation to clarify the roles of team members, including hospice nurses.

Report on palliative sedation medication usage: a survey of palliative care experts in Eight European countries

BackgroundThe practice of palliative sedation continues to raise ethical questions among people, which in turn leads to its varied acceptance and practice across regions. As part of the Palliative Sedation European Union (EU) project, the aim of the present study was to determine the perceptions of palliative care experts regarding the practice of palliative sedation in eight European countries (The Netherlands, Belgium, Germany, UK, Italy, Spain, Hungary, and Romania).MethodsA specifically designed survey, including questions on the most frequently used medications for palliative sedation, their availability per countries and settings, and the barriers and facilitators to the appropriate practice of palliative sedation was sent to expert clinicians involved and knowledgeable in palliative care in the indicated countries. A purposive sampling strategy was used to select at least 18 participating clinicians per consortium country. Descriptive statistical analysis was conducted on the survey data.ResultsOf the 208 expert clinicians invited to participate, 124 participants completed the survey. Midazolam was perceived to be the most frequently used benzodiazepine in all eight countries. 86% and 89% of expert clinicians in Germany and Italy, respectively, perceived midazolam was used “almost always”, while in Hungary and Romania only about 50% or less of the respondents perceived this. Levomepromazine was the neuroleptic most frequently perceived to be used for palliative sedation in the Netherlands, Spain, Germany, and the United Kingdom. Between 38- 86% of all eight countries´ expert clinicians believed that opioid medications were “almost always” used during palliative sedation. The perceived use of IV hydration and artificial nutrition “almost always” was generally low, while the country where both IV hydration and artificial nutrition were considered to be “very often” given by a third of the expert clinicians, was in Hungary, with 36% and 27%, respectively.ConclusionsOur study provides insight about the differences in the perceived practice of medication during palliative sedation between eight European countries. In countries where palliative care services have been established longer perceptions regarding medication use during palliative sedation were more in line with the recommended European guidelines than in Central and Eastern European countries like Romania and Hungary.

Bispectral Index monitoring of palliative sedation for home withdrawal of tracheostomy ventilation: A case report.

Tracheostomy ventilation in motor neurone disease is an uncommon life-sustaining treatment. Best practice is having a plan for ventilation withdrawal, but the literature to guide practice is limited. Case reports have documented standard doses of opioids and benzodiazepines used for sedation in such cases. A 49-year-old man was diagnosed with motor neurone disease in 2016. He commenced tracheostomy ventilation in 2018. In 2022 and 2023, planning was undertaken, at the patient's request, for withdrawal of tracheostomy ventilation at home, when he was no longer able to communicate with technology. Planning included Bispectral Index monitoring prior to cessation of ventilation, ensuring this only occurred when deep sedation was achieved. After ventilation withdrawal in 2023, a retrospective review of medications given and his level of sedation on monitoring was undertaken, with family consent. Ventilation withdrawal was initiated after deep sedation was achieved, 6 h after commencing subcutaneous infusions of morphine, midazolam, clonazepam and phenobarbital. Doses required to achieve acceptable sedation exceeded literature reports. Achieving deep sedation was a longer than expected process. More research using an objective measure of sedation is required, as clinical assessment of sedation in this context is compromised.

Psychological adjustment and perception of patients’ relatives and healthcare providers regarding continuous deep sedation until death: A mixed-methods study.

12098 Background: France is currently in the midst of societal discussions concerning new legislation on active assistance in dying. Continuous Deep Sedation Until Death (CDSUD) is considered by some a “French exception” since 2016, but 8 years later, findings suggest that this procedure is not really clear to all, including patients, their relatives and their healthcare providers (HCP). The primary objective of this original research is to document the psychological adjustment of patients’ relatives and HCPs in the cancer context. Methods: APSY-SED (ID-RCB 2021-A03042-39) is a multicentric prospective, longitudinal and observational study, using a mixed-methods design. A lexicometric analysis of the semi-structured interviews was performed using Iramuteq software. A questionnaire survey was conducted, encompassing for relatives: anxiety and depressive symptoms (STAI-S, BDI-II); for HCPs: Professional Stress and Professional experience (Karasek questionnaire). We present here the main results at T1 (when CDSUD is implemented). Results: Main quantitative results are presented in Table I. Regarding qualitative findings, fifteen research interviews with relatives and 15 interviews with HCP were analyzed. Most frequent words associated with CDSUD were its “objectives”, its specific “temporality”, the mention of “euthanasia”, and “saying goodbye”. Confusion between CDSUD and euthanasia persists in relatives and HCPs. Conclusions: On average, relatives reported severe anxiety in the context of CDSUD. The qualitative findings regarding the main concerns shared by the relatives concerning the CDSUD temporality perceived as brutal, shed light on this anxiety. The second assessment time of this study, 6 months after death, including measures of depression, anxiety, intensity of grief reactions, will allow to specify the adjustement at mid-term. This is the first empirical study carried out in France on the adjustment of relatives and HCPs caring for patients with cancer for whom CDSUD is discussed. [Table: see text]

Continuous Sedation in Palliative Care in Portugal: A Prospective Multicentric Study.

Objective: This study aimed to survey the practice of palliative sedation in Portugal, where data on this subject were lacking. Methods: This was a prospective multicentric study that included all patients admitted to each team that agreed to participate. Patients were followed until death, discharge, or after 3 months of follow-up. Results: The study included 8 teams: 4 as palliative care units (PCU), 1 as a hospital palliative care team (HPCT), 2 as home care (HC), and 1 as HPCT and HC. Of the 361 patients enrolled, 52% were male, the median age was 76 years, and 285 (79%) had cancer. Continuous sedation was undergone by 49 (14%) patients: 26 (53%) were male, and the median age was 76. Most patients, 46 (94%), had an oncological diagnosis. Only in a minority of cases, the family, 16 (33%), or the patient, 5 (10%), participated in the decision to sedate. Delirium was the most frequent symptom leading to sedation. The medication most used was midazolam (65%). In the multivariable analysis, only age and the combined score were independently associated with sedation; patients <76 years and those with higher levels of suffering had a higher probability of being sedated. Conclusions: The practice of continuous palliative sedation in Portugal is within the range reported in other studies. One particularly relevant point was the low participation of patients and their families in the decision-making process. Each team must have a deep discussion on this aspect.

Medication strategies: enhancing symptom management and quality of life in palliative care

Background: Palliative care is integral to addressing suffering during advanced illnesses, and tailored medication is crucial. This study aims to explore medication patterns in palliative care, focusing on understanding their impact on symptom management and patient well-being. Methods: Data collection involves a retrospective approach with patients referred to the Community Support Team in Palliative Care of the Trás-os-Montes and Alto Douro Local Health Unit between April 2022 and March 2023. Data are recorded, including demographic information, medical history, and pain-related details. Medication is administered based on healthcare professionals’ judgment, following established pain management guidelines. Descriptive and cross-tabulation techniques are employed for the statistical analysis. Results: Key findings highlight Morphine and Paracetamol as primary analgesics, constituting 14.6% and 13.8%, respectively. Fentanyl, identified as a potent opioid, addresses severe pain at a rate of 10.0%. The study also reveals that 23.7% of cancer patients receive palliative sedation, emphasising its role in symptom control and dignified care. Conclusions: This research provides significant insights into the intricate relationship between medication administration and palliative care outcomes. The study reveals key findings, such as the prominence of Morphine, Paracetamol, and Fentanyl as essential analgesics in addressing pain and improving patient comfort. Additionally, the high prevalence of palliative sedation among cancer patients underscores its crucial role in symptom control and ensuring dignified care at the end of life. The complexity of medication choices within palliative care settings is emphasised, highlighting the need for careful consideration and tailored approaches.

Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences.

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. This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. We conducted a qualitative study based on focus group discussions. 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. 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. 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.

Ethics Consult: Using Hospice as "Treatment" for Behavioral Problems of Dementia

Patients with Behavioral and Psychological Symptoms of Dementia (BPSD) are among the most challenging patients to treat; these behaviors are estimated to occur in up to 90% of patients with dementia (Aigbogun 2019); of these, one in 5 patients displays aggression (Eastley 1997). The usual treatments have only modest efficacy at best and at times are ineffective in some individuals. Some behaviors such as physical aggression make it difficult, if not impossible, to find placement for these patients. Placement in nursing homes on a hospice status have traditionally required evidence of a 6 month life expectancy; placement in an inpatient hospice setting is usually reserved for patients with even shorter life expectancies such as 2 weeks. Prognosticating life expectancy in patients with dementia is challenging and often inaccurate (Jayes 2004). Furthermore the use of terminal palliative sedation is supposed to be confined to the last 2 weeks of life and/or extreme physical suffering (Schuman-Oliver 2008, AMA Opinion 2013).This session will present 2 cases of individuals with advanced dementia who did not meet the traditional Medicare criteria for hospice, as both were ambulatory and did not have significant co-morbid medical issues. Both had significant aggressive behaviors that responded poorly to extensive trials of various medications during extended stays on a geriatric psychiatry inpatient unit. Both were referred to a local inpatient hospice where the staff use “suffering" as a hospice criteria and were “treated” with the usual hospice medications and expired in less than 3 weeks.This session will use the two clinical cases to address the following: review the issue of prognostication of advanced dementia and the challenges of defining the end of life; review efforts to define “suffering” in advanced dementia in both the medical and ethics literature; review issues concerning palliative sedation; define how this differs from medical aid in dying and euthanasia. The experience of Dutch geriatricians addressing these issues will be presented (Veldwijck-Rouenhorst 2021). A geriatric psychiatrist will present the 2 cases and set up the questions and ethical issues that these cases pose. An ethics professor-scholar from Emory University will review the ethics literature and teachings that address these issues and help lead a discussion with the audience. The overall goal is to provide a framework of steps the audience members can take if confronted with similar cases.

Euthanasia - A Novel Intricacy for Psychiatry’s Purview?

IntroductionNumerous countries, notably within Europe, have sanctioned the practice of euthanasia. Extant legal frameworks meticulously define the extent, essence, and application of euthanasia, encompassing divergent characterizations, explications of entitlements, procedural modalities, and provisions for access. Nonetheless, the precise function of psychiatrists within these legislative contours remains conspicuously nebulous.ObjectivesThe present inquiry undertakes a comprehensive evaluative review of the euthanasia phenomenon vis-à-vis the intricate tapestry of European legislative paradigms, with an emphasis on elucidating the multifaceted involvement of psychiatry within this evolving landscape.MethodsA nuanced narrative review is undertaken, encapsulating the contemporary state-of-affairs, fundamental conceptual architectures, the tenets of the Spanish Organic Law 03/2021, and the pharmaceutic armamentarium deployed in the orchestration of euthanasic practices. Additionally, the methodological blueprint employed within a prominent tertiary healthcare institution situated in Madrid is meticulously expounded.ResultsTo date, euthanasia has garnered legal imprimatur across diverse jurisdictions including, but not limited to, the Netherlands, Belgium, Colombia, Canada, Spain, and New Zealand. The ambit of assisted death and its application to the domain of mental infirmities is meticulously deconstructed. Within the overarching realm of foundational concepts, a rigorous delineation is rendered between euthanasia, medical succor in the throes of mortality, assisted self-termination, facilitated demise, provision of mortal release, judicious calibration of therapeutic enterprise, and the contours of palliative sedation. Distinction between the principal executor and the advisory consultant is rendered salient. The rubric of conscientious objection emerges as an inviolable entitlement of healthcare practitioners enmeshed in the provisionary matrix.The enduring incumbency of the psychiatrist as a pivotal appraiser of cognitive and volitional faculties holds firm. The conspicuous influence of psychopathological constellations upon the contours of euthanasia eligibility precipitates cogent deliberation.ConclusionsAs the frontiers of euthanasia expand to encompass an augmented array of legal jurisdictions, this study underscores the increasingly intricate role inhabited by psychiatrists in the matrix of evaluative assessments. The proclivity of mental maladies to exert a substantial gravitational pull upon determinations of eligibility for euthanasia accentuates the exigency for refined explication of roles and responsibilities within this evolving sphere, a clarion call resonant not only within the precincts of psychiatry but reverberating across the broader firmament of medical praxis.Disclosure of InterestNone Declared

Noninvasive monitoring technologies to identify discomfort and distressing symptoms in persons with limited communication at the end of life: a scoping review

BackgroundDiscomfort and distressing symptoms are common at the end of life, while people in this stage are often no longer able to express themselves. Technologies may aid clinicians in detecting and treating these symptoms to improve end-of-life care. This review provides an overview of noninvasive monitoring technologies that may be applied to persons with limited communication at the end of life to identify discomfort.MethodsA systematic search was performed in nine databases, and experts were consulted. Manuscripts were included if they were written in English, Dutch, German, French, Japanese or Chinese, if the monitoring technology measured discomfort or distressing symptoms, was noninvasive, could be continuously administered for 4 hours and was potentially applicable for bed-ridden people. The screening was performed by two researchers independently. Information about the technology, its clinimetrics (validity, reliability, sensitivity, specificity, responsiveness), acceptability, and feasibility were extracted.ResultsOf the 3,414 identified manuscripts, 229 met the eligibility criteria. A variety of monitoring technologies were identified, including actigraphy, brain activity monitoring, electrocardiography, electrodermal activity monitoring, surface electromyography, incontinence sensors, multimodal systems, and noncontact monitoring systems. The main indicators of discomfort monitored by these technologies were sleep, level of consciousness, risk of pressure ulcers, urinary incontinence, agitation, and pain. For the end-of-life phase, brain activity monitors could be helpful and acceptable to monitor the level of consciousness during palliative sedation. However, no manuscripts have reported on the clinimetrics, feasibility, and acceptability of the other technologies for the end-of-life phase.ConclusionsNoninvasive monitoring technologies are available to measure common symptoms at the end of life. Future research should evaluate the quality of evidence provided by existing studies and investigate the feasibility, acceptability, and usefulness of these technologies in the end-of-life setting. Guidelines for studies on healthcare technologies should be better implemented and further developed.

The risk of delirium after sedation with propofol or midazolam in intensive care unit patients.

Knowledge of risk factors may provide strategies to reduce the high burden of delirium in intensive care unit (ICU) patients. We aimed to compare the risk of delirium after deep sedation with propofol versus midazolam in ICU patients. In this prospective cohort study, ICU patients who were in an unarousable state for ≥24 h due to continuous sedation with propofol and/or midazolam were included. Patients admitted ≤24 h, those with an acute neurological disorder and those receiving palliative sedation were excluded. ICU patients were assessed daily for delirium during the 7days following an unarousable state due to continuous sedation. Among 950 included patients, 605 (64%) subjects were delirious during the 7days after awaking. The proportion of subsequent delirium was higher after midazolam sedation (152/207 [73%] patients) and after both propofol and midazolam sedation (257/377 [68%] patients), compared to propofol sedation only (196/366 [54%] patients). Midazolam sedation (adjusted cause-specific hazard ratio [adj. cause-specific HR] 1.32, 95% confidence interval [CI] 1.05-1.66) and propofol and midazolam sedation (adj. cause-specific HR 1.29, 95% CI 1.06-1.56) were associated with a higher risk of subsequent delirium compared to propofol sedation only. This study among sedated ICU patients suggests that, compared to propofol sedation, midazolam sedation is associated with a higher risk of subsequent delirium. This risk seems more apparent in patients with high cumulative midazolam intravenous doses. Our findings underpin the recommendations of the Society of Critical Care Medicine Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guidelines to use propofol over benzodiazepines for sedation in ICU patients.

A Dutch paediatric palliative care guideline: a systematic review and evidence-based recommendations for symptom treatment

BackgroundChildren with life-threatening and life-limiting conditions can experience high levels of suffering due to multiple distressing symptoms that result in poor quality of life and increase risk of long-term distress in their family members. High quality symptom treatment is needed for all these children and their families, even more so at the end-of-life. In this paper, we provide evidence-based recommendations for symptom treatment in paediatric palliative patients to optimize care.MethodsA multidisciplinary panel of 56 experts in paediatric palliative care and nine (bereaved) parents was established to develop recommendations on symptom treatment in paediatric palliative care including anxiety and depression, delirium, dyspnoea, haematological symptoms, coughing, skin complaints, nausea and vomiting, neurological symptoms, pain, death rattle, fatigue, paediatric palliative sedation and forgoing hydration and nutrition. Recommendations were based on evidence from a systematic literature search, additional literature sources (such as guidelines), clinical expertise, and patient and family values. We used the GRADE methodology for appraisal of evidence. Parents were included in the guideline panel to ensure the representation of patient and family values.ResultsWe included a total of 18 studies that reported on the effects of specific (non) pharmacological interventions to treat symptoms in paediatric palliative care. A few of these interventions showed significant improvement in symptom relief. This evidence could only (partly) answer eight out of 27 clinical questions. We included 29 guidelines and two textbooks as additional literature to deal with lack of evidence. In total, we formulated 221 recommendations on symptom treatment in paediatric palliative care based on evidence, additional literature, clinical expertise, and patient and family values.ConclusionEven though available evidence on symptom-related paediatric palliative care interventions has increased, there still is a paucity of evidence in paediatric palliative care. We urge for international multidisciplinary multi-institutional collaboration to perform high-quality research and contribute to the optimization of symptom relief in palliative care for all children worldwide.

Consciously Choosing Unconsciousness

Consciously Choosing Unconsciousness

Quelle connaissance et quelle perception ont les professionnels de santé d’un Centre de lutte contre le cancer à propos des pratiques palliatives encadrées par la loi Claeys-Leonetti : étude PAL PRAT

Introduction: The issue of end-of-life care is the subject of a sensitive debate in French society, particularly regarding the possibility for certain patients to have access to medical assistance in dying. The aim of this study was to assess the knowledge and opinion of healthcare providers on the care practices for patients at the end of life, as well as to highlight any specificities in their discourse.Method: A survey of healthcare providers' opinions, composed of closed and open questions, that were analyzed using a lexicometric approach, was distributed in a cancer center.Results: The results of the study reveal a good knowledge of the different procedures. Professionals considered that advance directives should be systematically collected; a majority of them differentiated euthanasia from deep continuous sedation and perceived the latter as a means of relieving patients' suffering without inducing death. The different procedures related to the active assistance in dying were known by a majority of professionals and the survey did not identify a dominant trend concerning the will to practice euthanasia if the legal framework allowed it. Half of the participants considered their training insufficient, indicating the need to fill this gap.Discussion: This survey underlines the importance of training and support for the professionals caring for patients in palliative situation and their relatives in France.