Palliative Sedation Research Articles

Ética en la toma de decisiones en enfermería, dilemas en el cuidado de pacientes terminales

The article addresses the ethical dilemmas faced by nurses in the care of terminally ill patients, exploring the tension between patient autonomy, family expectations and institutional guidelines. Through a qualitative literature review, the main ethical dilemmas were identified, such as the use of palliative sedation, limiting invasive treatments, and making decisions in contexts where patients are unable to express their wishes. The results highlight that nurses experience moral stress when faced with decisions that could unnecessarily prolong the patient's suffering or go against their autonomy. It is concluded that there is a need to strengthen ethical training and institutional support through the creation of interdisciplinary ethics committees and the promotion of a culture of open communication. These strategies can improve ethical decision making and reduce the emotional impact on professionals.

Cross-cultural comparison of continuous deep sedation for advanced cancer patients in East Asian countries: prospective cohort study.

Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan. Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries. A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001). Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country.

Existential suffering as a motive for assisted suicide: Difficulties, acceptability, management and roles from the perspectives of Swiss professionals.

Existential suffering is often a part of the requests for assisted suicide (AS). Its definitions have gained in clarity recently and refer to a distress arising from an inner realization that life has lost its meaning. There is however a lack of consensus on how to manage existential suffering, especially in a country where AS is legal and little is known about the difficulties faced by professionals confronted with these situations. To explore the perspectives of Swiss professionals involved in end-of-life care and AS on the management of existential suffering when it is part of AS requests, taking into account the question of roles, as well as on the difficulties they encounter along the way and their views on the acceptability of existential suffering as a motive for AS. A qualitative study based on face-to-face interviews was performed among twenty-five participants from the fields of palliative and primary care as well as from EXIT right-to-die organization. A semi-structured interview guide exploring four themes was used. Elements from the grounded theory approach were applied. Almost all participants reported experiencing difficulties when facing existential suffering. Opinions regarding the acceptability of existential suffering in accessing AS were divided. Concerning its management, participants referred to the notion of being present, showing respect, seeking to understand the causes of suffering, helping give meaning, working together, psychological support, spiritual support, relieving physical symptoms and palliative sedation. This study offers a unique opportunity to reflect on what are desirable responses to existential suffering when it is part of AS requests. Existential suffering is plural and implies a multiplicity of responses as well. These situations remain however difficult and controversial according to Swiss professionals. Clinicians' education should further address these issues and give professionals the tools to better take care of these people.

The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review

BackgroundClinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients’ situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS.ObjectivesTo describe the clinical practice of PS in patients with COVID versus non-COVID patients.MethodsA retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March ’20 and January ‘21 were included.ResultsDuring the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08).ConclusionPS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.

Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams.

Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for healthcare teams and families. Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016. We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019. Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n=5 cases), Chlorpromazine (n=3), Ketamine (n=2) and Propofol (n=2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction. Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.

Effect of Dexmedetomidine for Palliative Sedation for Refractory Dyspnoea in Patients with Terminal-Stage Cancer.

Dyspnoea affects a considerable percentage of patients with terminal-stage cancer, and clinical guidelines recommend palliative sedation for patients with refractory dyspnoea. Midazolam is currently the most commonly used sedative; however, it can cause serious adverse reactions, such as respiratory/circulatory depression. Hence, there is a need for an alternative sedative. Dexmedetomidine (DEX) is a promising alternative as its "awake sedation" effect; however, little is known regarding its use in patients with end-stage dyspnoea. Therefore, the aim of this study was to determine the safety and usefulness of DEX for palliative sedation of patients with refractory dyspnoea. This retrospective study included patients with terminal-stage cancer who received DEX for palliative sedation owing to refractory dyspnoea in the hospice ward from January 2018 to October 2022. We analysed their general data, dyspnoea conditions, sedation details, sedative treatment effect, dyspnoea relief, and changes in vital signs before and after sedation, via paired t-tests. We included 17 patients with terminal-stage cancer who received DEX palliative sedation at a dose of 0.2-0.9 µg/kg·h for refractory dyspnoea, among whom 6 (35%) received a loading dose of 1 µg/kg in 10 min. After 1 h of sedation and at the maximum sedation dose, the Respiratory Distress Observation Scale and Richmond Agitation-Sedation Scale scores decreased significantly compared with those before sedation (all P<0.001), as did the respiratory rate (P=0.024 and P=0.008, respectively). The heart rate and blood oxygen saturation did not significantly change, whereas the systolic and diastolic blood pressure after 1 h of sedation were significantly lower than those before sedation (both P=0.015). DEX is a promising palliative sedative for patients with terminal-stage cancer, as it safely relieved the symptoms of refractory dyspnoea without inducing serious adverse reactions. Therefore, DEX may greatly enhance the quality of life for patients with terminal-stage cancer.

Should Benzodiazepines be Used for Reducing Dyspnea in Patients with Advanced Illnesses?

Dyspnea is a common and highly distressing symptom in patients with advanced illnesses. Many patients continue to experience chronic dyspnea despite optimal management of underlying disease(s) and various non-pharmacologic interventions, necessitating the consideration of pharmacologic therapies for palliation of dyspnea. One commonly asked question by clinicians is whether benzodiazepines have a role in the palliation of dyspnea. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups suggest that benzodiazepines alone do not confer a benefit for dyspnea in advanced illnesses based on existing data. They also expressed concerns about the potential adverse effects such as delirium and drowsiness and recommended against benzodiazepines as first line pharmacologic therapy. Some groups suggest that benzodiazepines may be used in highly selected patients with severe anxiety associated with dyspnea. Some investigators may also consider the adjunctive use of benzodiazepines in patients with severe dyspnea despite opioids, particularly if life expectancy is limited. Benzodiazepines also have a role in palliative sedation for refractory dyspnea in the last days of life. More research is needed to confirm the benefit of benzodiazepines in these populations.

To Create or Not to Create: How to Establish a System-Wide Proportionate Palliative Sedation Guideline Through Comprehensive Interdisciplinary Collaboration (TH108A)

To Create or Not to Create: How to Establish a System-Wide Proportionate Palliative Sedation Guideline Through Comprehensive Interdisciplinary Collaboration (TH108A)

Colleague Agitation in Pediatric Palliative Sedation: A Call to Action for National Protocolization (SA301B)

Colleague Agitation in Pediatric Palliative Sedation: A Call to Action for National Protocolization (SA301B)

A Case-Based Approach to Palliative Sedation Therapy (PST) (FR226A)

A Case-Based Approach to Palliative Sedation Therapy (PST) (FR226A)

Hospice as “treatment” for BPSD: finding an ethical way forward

Patients with Behavioral and Psychological Symptoms of Dementia can be among the most challenging patients to treat. Even when their behaviors improve with treatment, just the history of their behaviors can make them difficult to place in a nursing home or memory care unit. Historically hospice has only been used as an option for patients who meet the Medicare criteria for hospice; however, prognostication of likelihood of death within 6 months is difficult to do, even in patients with advanced dementia. Other criteria such as the ADEPT criteria have been used, though prognostication is difficult even with these criteria. Quality of Life and suffering are not technically hospice criteria in the USA; furthermore, defining quality of life in advanced dementia is challenging and suffering in dementia patients has never really been operationalized, except in patients with overt signs of distress such as screaming.This session will present a case of a man with advanced dementia who did not meet the traditional criteria for hospice, as he was fully ambulatory, able to feed himself finger foods and even able to enjoy listening and dancing to his favorite music. He had only lost 2 pounds over the past year, even though his weight was 50lbs lower than it had been in his prime, when he lived in the community. He had no ongoing medical comorbidities that would shorten his life; he had pulled through 2 bouts of COVID without issue during his time on the unit. He had a significant history of aggression which, at the time of the hospice referral, mostly came out sporadically when resisting care or with redirection from wandering into the rooms of other patients. He had some other undesirable behaviors such as urinating on the floor. He had been previously kicked out of a couple of nursing homes because of aggressive behavior towards other residents. He had been cared for on a geripsychiatry unit for 10 months, as his history made him unplaceable in conventional nursing homes and the option of a state hospital placement was not available. The palliative care doctor and the director of a hospice with an academic affiliation decided to use his pacing as a sign of "suffering" and contended that the usual treatment for BPSD (which included antipsychotics and mood stabilizers) on the geripsychiatry unit was prolonging his life and hence his "suffering". The palliative care doctor referred to him as a "hothouse flower"; she presented hospice the best option to the family (who had barely visited him in the 10 months he was on the unit) and they enthusiastically espoused this course of treatment. He was referred to the main inpatient hospice where he received palliative sedation and expired within 2 weeks.This case will examine the process of this referral; attempt to clarify the underlying prejudices of some of the parties involved towards patients with dementia that may have driven some of the decision-making; clarify some of the ethical issues in the decision-making to use hospice for this problematic patient. The experience in the Netherlands where some geriatricians have published their experience with palliative sedation in BPSD and have even developed a workgroup with guidelines will be reviewed as well.

Pain management in German specialized outpatient palliative care : Across-sectional study to present the current pain management of palliative patients in the home environment

With the help of specialized outpatient palliative care teams (German abbreviation: SAPV), seriously ill and dying patients in Germany can be adequately cared for in their home environment until the end of their lives; however, there are no uniform standards or guidelines for well-executed pain management right now. This approach serves as basic research in the field of public health research. This is intended to present which methods (use of different professional groups, use of pain medications, alternative medical treatment etc.) the individual SAPV teams use for pain management. From this it can be deduced which procedures can be considered particularly effective. This cross-sectional study was conducted in May 2021. All German SAPV teams (n = 307) listed on the homepage of the German Association for Palliative Medicine (DGP) were contacted by post and invited to participate. Atotal of 175 teams (57%) responded to the request and were included in the evaluation. Adescriptive data analysis was performed. Pain management in the German outpatient care of palliative patients is based on several components. All common pain medications are used, but primarily metamizole (99.4%) as anon-opioid analgesic, morphine (98.3%) from the opiate series and pregabalin (96.6%) as aco-analgesic are mainly prescribed. If pain therapy fails, 22.5% of the SAPV teams perform palliative sedation for symptom control on aregular basis. This cross-sectional study is the first of its kind to provide ageneral overview of the treatment options for pain management in German outpatient palliative care. In comparison with international studies, the question arises as to whether uniform therapy schemes and areduction in the medication available in the individual SAPV teams could lead to an improvement in patient care.

Dyspnea in Oncological Patients: a Brain Teaser.

Dyspnea is one of the most common symptoms in oncological patients with greater prevalence in lung cancer and advanced disease states. Causes of dyspnea can be directly or indirectly associated with cancer, anti-neoplastic therapies and comorbidities unrelated to cancer. Routine screening of dyspnea is suggested for all oncological patients by using unidimensional, simple scales and multidimensional tools to capture more domains affected by this symptom and to assess the effectiveness of interventions. The first step in the treatment algorithm of dyspnea is the identification of potentially reversible causes; if no specific cause is depicted, symptomatic treatment with non-pharmacological and pharmacological interventions is suggested. Referral to palliative care and continuous palliative sedation are the last resort in patients with a very limited life expectancy of not more than a few days for symptomatic relief and to decrease of the distress of patients and caregivers.

Pain Management in Palliative Care

Patients in the palliative phase of a disease often suffer from pain, which leads to a significant reduction in quality of life. Since in most cases there is a progression rather than an improvement of the disease over time, pain therapy must also be dynamically adapted. Due to accompanying symptoms and the physical burden of the disease, treatment of pain is often difficult. In the palliative situation, pain should not only be understood as an excitation of nociceptors but is rather also an expression of mental stress. In this article, we would like to give an overview of the available drugs, application methods and alternative treatment options. Specifically, the article is divided into the following subsections: non-opioid analgesics, opioids, co-analgesics, patient-controlled analgesia procedures, neuraxial and peripheral regional anesthesia procedures, neurolysis, supportive therapies and palliative sedation. Thus, when treating palliative patients, the focus should not only be on the one symptom of pain, but, in the sense of the bio-psycho-social model, a multimodal oriented treatment of the patient with all his symptoms, also including his relatives, must be carried out.

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART.

Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia. A 15-month, stepped-wedge, cluster-randomized trial. Every 3months, a nursing home switched from care as usual to the use of the intervention. The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents. We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness. The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction). The mean age of the residents (n= 97) at enrollment was 86.5 ± 6.7years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7,-2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7). MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Palliative Sedation in the Home Setting #451

Palliative Sedation in the Home Setting #451

Monitoring the clinical practice of palliative sedation (PALSED) in patients with advanced cancer: an international, multicentre, non-experimental prospective observational study protocol

BackgroundPalliative sedation involves the intentional lowering of consciousness at the end of life. It can be initiated to relieve a patient’s burden caused by refractory symptoms at the end of life. The impact of palliative sedation needs to be clinically monitored to adjust the proper dose and regimen of sedative medication to ensure that patients are at ease and comfortable at the end of their lives. Although there is consensus among health care professionals and within guidelines that efficacy of palliative sedation needs to be closely monitored, there is no agreement about how, when, and by whom, this monitoring should be performed. The aim of this study is to evaluate the effects of palliative sedation by measuring the discomfort levels and sedation/agitation levels of the patients at regular timepoints. In addition, the clinical trajectories of those patients receiving palliative sedation will be monitored and recorded.MethodsThe study is an international prospective non-experimental observational multicentre study. Patients are recruited from in-patient palliative care settings in Belgium, Germany, Italy, Spain and the Netherlands. Adult patients with advanced cancer are monitored by using proxy observations of discomfort (DS-DAT) and depth of sedation/agitation levels (RASS-PAL) during palliative sedation. After the palliative sedation period, the care for the specific participant case is evaluated by one of the attending health care professionals and one relative via a questionnaire.DiscussionThis study will be the first international prospective multicenter study evaluating the clinical practice of palliative sedation including observations of discomfort levels and levels of sedation. It will provide valuable information about the practice of palliative sedation in European countries in terminally ill cancer patients. Results from this study will facilitate the formulation of recommendations for clinical practice on how to improve monitoring and comfort in patients receiving palliative sedation.Trial registrationThis study is registered at Clinicaltrials.gov since January 22, 2021, registration number: NCT04719702.

Information and Advance Care Directives for End-of-Life Residents with and without Dementia in Nursing Homes.

Communication and advance care directives may be affected by the presence of dementia. We sought to describe the information and end-of-life preferences provided to nursing homes residents and their families. Trained nurses collected information from 124 residents randomly selected with palliative care needs from eight nursing homes. A total of 54.4% of the residents with dementia had been provided with information about their state of health, compared to 92.5% of the residents without dementia (p < 0.01); family members exhibited no differences regarding information (p = 0.658), regardless of whether the resident was cognitively impaired. Most advance care interventions remained unexplored, except for cases where a transfer to hospital (81.5%) or serotherapy (69.4%) was desired. Decisions regarding palliative sedation (p = 0.017) and blood transfusion (p = 0.019) were lower among residents with dementia. Residents, especially residents with dementia, are provided with limited information and their preferences are inadequately explored.

‘How is it possible that at times we can be physicians and at times assistants in suicide?’ Attitudes and experiences of palliative care physicians in respect of the current legal situation of suicide assistance in Switzerland

IntroductionSwitzerland lacks specific legal regulation of assistance in suicide. The practice has, however, developed since the 1980s as a consequence of a gap in the Swiss Criminal Code and is...

Palliative sedation in a hospital unit

A person at the end of life may present uncomfortable symptoms becoming refractory to an adequate treatment. In this case, the initiation of palliative sedation is indicated. Most sedated inpatients die outside a specialized palliative care unit. Palliative sedation must be initiated and adapted according to the best clinical practices. This article describes the processes associated with palliative sedation in a hospital unit.