Standard Process for Palliative Sedation in Peking Union Medical College Hospital / 中国医学科学院学报

End-stage patients experience unbearable pain because of refractory symptoms.Palliative sedation is a form of palliative care which relieves patients' agony by lowering their consciousness.Standard palliative sedation can help patients die with dignity.It is distinct from euthanasia and does not alter the survival of patients.Sufficient palliative care is the premise of palliative sedation.Repeated and detailed clinical evaluation,as well as multidisciplinary involvement,is necessary for the standardized implementation of palliative sedation.Here,we proposed the standard process and specifications of palliative sedation in Peking Union Medical College Hospital.Furthermore,we reported a case of palliative sedation for an advanced cancer patient with refractory delirium and living pain to demonstrate its application in clinical practice.

Nurses’ Experience in the Introduction of Palliative Sedation for Patients with Terminal Lung Cancer in Respiratory Medicine Wards

Palliative sedation (PS) is an effective way to alleviate the refractory symptom of terminally ill cancer patients, however it can be ethical. PS is now being implemented in general wards, and there is an urgent need to understand the actual conditions of sedation care for general ward nurses and improve the quality of care. In this study, a semi-structured interview was conducted with nurses working in a respiratory medicine ward of a core cancer treatment hospital. By Krippendorff’s content analysis, 16 categories of nurses’ actions/judgments, 8 categories of positive thoughts, and 5 categories of negative thoughts were extracted. Nurses have always sought the best way to alleviate the pain of patients and their families, and have endeavored to be close to their feelings. However, there was a difference in confidence and positivity regarding multidisciplinary collaboration and sedation discussions. It was suggested that the confident efforts of nurses may support the decision-making of patients and their families and consider methods for pain relief and QOL.

Perceptions of Nurses Involved in Patient Decision-making regarding Palliative Sedation

This study aimed to reveal the perceptions of nurses involved in patient decision-making regarding palliative sedation. Semi-structured interviews were conducted with six nurses working at hospices, and the data were qualitatively and descriptively analyzed. Nurses’ perception regarding “difficulties involved in the decision-making process,” “stance of placing emphasis on patients’ preferences,” and “coping behaviors for participating in the decision-making process” were identified. The nurses had difficulties associated with concerns about making patients conscious of death and carried a heavy burden, and it was suggested that they find it difficult to explain sedation or confirm patients’ preferences. On the other hand, the nurses relied on their moral principles to make judgments, showing that they try to emphasize patients’ preferences. Multidisciplinary discussions are needed to provide psychological support for nurses involved in patient decision-making on palliative sedation. In terms of the educational aspect, the need for experiences was cited, suggesting that it is necessary to educate nurses through hands-on activities such as role-playing exercises concerning making decisions about sedation.

Retrospective Survey of Palliative Sedation Therapy at the End-of-life at a Tertiary Cancer Center in Japan

Although palliative sedation therapy (PST) is considered to alleviate intolerable and refractory symptoms in dying patients with advanced cancer, there have been few studies regarding the situation of tertiary cancer center. We conducted a retrospective survey of the medical records of the patients who died between April 2015 and March 2016 at the National Cancer Center Hospital in Japan. PST was conducted in 75 out of 431 patients (17.4%). The patient demographics were as follows: sex (male/female), 48/27; median age, 61 years (range 5-83; 11 patients (14.7%) were aged under 39 years); and primary sites were lung, 18 (24.7%)/ pancreas, 11 (14.7%)/ hematopoietic organs, 11 (14.7%)/ bones and soft tissues, 8 (10.7%)/ and the others, 27 (36.0%). The main target symptoms for PST were dyspnea (38, 50.7%) and delirium (30, 40.0%). The most commonly used sedative agent was midazolam (72, 96.0%). Continuous deep sedation was intended in 61 patients (81.3%) at the death. Median survival from the start of PST were 2 days (range 0-54). The differences between palliative care team (PCT) intervention group and control group were lower age (58 vs. 62.5, P=0.048) and uniformity of initial midazolam dose (5-12 vs. 9.6-25.2 mg/day). Distinctive feature in this study was large proportion of adolescent and young adult patients with rare cancers. PCT might have different approaches to sedation in comparison to non-PCT medical staffs.

The role of end-of-life palliative sedation: medical and ethical aspects - Review / O papel da sedação paliativa no fim da vida: aspectos médicos e éticos - Revisão

Abstract Background and objective: Palliative sedation is a medical procedure that has been used for more than 25 years to relieve refractory symptoms not responsive to any previous treatment in patients with no possibility of cure and near the end of life. Many uncertainties persist on the theme regarding definition, indications, decision making, most appropriate place to perform the procedure, most used drugs, need for monitoring, fluids and nutritional support, and possible ethical dilemmas. The objective of this review was to seek a probable consensus among the authors regarding these topics not yet fully defined. Method: An exploratory search was made in secondary sources, from 1990 to 2016, regarding palliative sedation and its clinical and bioethical implications. Conclusions: Palliative sedation is an alternative to alleviate end-of-life patient suffering due to refractory symptoms, particularly dyspnea and delirium, after all other treatment options have been exhausted. Decision making involves prior explanations, discussions and agreement of the team, patient, and/or family members. It can be performed in general hospital units, hospices and even at home. Midazolam is the most indicated drug, and neuroleptics may also be required in the presence of delirium. These patients' monitoring is limited to comfort observation, relief of symptoms, and presence of adverse effects. There is no consensus on whether or not to suspend fluid and nutritional support, and the decision must be made with family members. From the bioethical standpoint, the great majority of authors are based on intention and proportionality to distinguish between palliative sedation, euthanasia, or assisted suicide.

Resumo Justificativa e objetivo: Sedação paliativa é um procedimento médico que tem sido empregado há mais de 25 anos com a finalidade de aliviar sintomas refratários que não respondem a tratamento anterior em pacientes sem possibilidade de cura e próximos do fim da vida. Muitas incertezas persistem sobre o tema no que diz respeito à definição, às indicações, à tomada de decisão, ao local mais adequado para fazer o procedimento, aos fármacos mais usados, à necessidade de monitoração, ao apoio hídrico e nutricional e aos possíveis dilemas éticos. O objetivo desta revisão foi o de buscar um provável consenso entre os autores em relação a esses tópicos ainda não totalmente definidos. Método: Foi feita uma pesquisa exploratória em fontes secundárias, a partir de 1990 até 2016, a respeito de sedação paliativa e suas implicações clínicas e bioéticas. Conclusões: A sedação paliativa é uma opção para aliviar sofrimento de pacientes no fim da vida, devido a sintomas refratários, especialmente dispneia e delirium, após terem sido esgotadas todas as outras opções de tratamento. A tomada de decisão envolve explicações prévias, discussões e concordância da equipe, pacientes e ou parentes. Pode ser feita em unidades hospitalares gerais ou de retarguarda e mesmo no domicílio. Midazolam é o fármaco mais indicado, podendo ser necessários também neurolépticos na presença de delirium. A monitoração desses pacientes se resume apenas à observação do conforto, do alívio dos sintomas e da presença de efeitos adversos. Não existe consenso em suspender ou não o apoio hídrico e nutricional; a decisão deve ser tomada junto aos parentes. Do ponto de vista bioético, a grande maioria dos autores se fundamenta na intenção e na proporcionalidade para fazer a distinção entre sedação paliativa, eutanásia ou suicídio assistido.

¿La sedación paliativa acorta la vida de los pacientes? / Does Palliative Sedation Shorten the Lives of Patients? / A sedação paliativa encurta a vida dos pacientes?

Resumen El respeto por la vida humana es central en el acto médico. En pacientes terminales, los síntomas refractarios son nicho de sedación paliativa. Este artículo identifica, a partir de evidencia científica, la sobrevida en pacientes con sedación paliativa en comparación con aquellos que no la recibieron. Se realizó búsqueda de revisiones sistemáticas de 2000 a 2016, se analizaron metodológicamente y se compararon los resultados. Por razones metodológicas no se pudo realizar meta-análisis. Se concluye que la sedación paliativa terminal no acorta la vida de los pacientes. Se reformula la aplicación del principio de doble efecto relacionado con el posible acortamiento de la vida; el mal no deseado es la pérdida de la conciencia.

Abstract Respect for human life is central to medicine. In terminal patients, refractory symptoms are a niche of palliative sedation. This paper identifies, based on scientific evidence, the survival in patients who received palliative sedation as compared to those who didn't. We conducted a search for systematic reviews from 2000 to 2016, which were methodologically analyzed, and the results were then compared. For methodological reasons, meta-analysis could not be performed. It is concluded that terminal palliative sedation does not shorten patients' lives. The implementation of the principle of double effect related to the possible shortening of life was reformulated; the unwanted evil is the loss of consciousness.

Resumo O respeito pela vida humana é primordial na atuação médica. Em pacientes terminais, os sintomas refratários são lugar de sedação paliativa. Este artigo identifica, a partir de evidência científica, a sobrevida em pacientes com sedação paliativa em comparação com aqueles que não a receberam. Foi realizada uma busca de revisões sistemáticas de 2000 a 2016, os resultados foram analisados metodologicamente e comparados. Por razões metodológicas, não foi possível realizar metanálise. Conclui-se que a sedação paliativa terminal não encurta a vida dos pacientes. A aplicação do princípio de duplo efeito relacionado com o possível encurtamento da vida é reformulada; o mal indesejado é a perda de consciência.

Palliative sedation for terminally ill cancer patients at home in Japan：A retrospective analysis

Some terminally ill cancer patients are treated with palliative sedation（PS）to alleviate their suffering. There have been very few studies in Japan investigating PS in the home. Thus, the aim of the present study was to investigate PS at home for terminally ill patients. A retrospective chart review was performed of 117 cancer patients who died at home between August 2012 and July 2014. Of the 73 who patients died at home, 24（33％）had received PS. The mean duration of PS was 4.4±6.0 days. Patients receiving PS were started on a mean dose of 12.8±6.2 mg/day midazolam；the mean dose at the end of PS was 12.4±6.5 mg/day midazolam. The primary reason for starting PS was delirium（n＝22）. PS in the home was feasible and was an essential treatment for cancer patients at home. We conclude that PS can be used safely and efficaciously to treat terminally ill cancer patients with refractory symptoms in their own home.

Midazolam en la sedación paliativa terminal de pacientes con cáncer / Midazolam in the terminal palliative sedation in patients with cancer

Objetivo: Describir el uso del midazolam en pacientes con cáncer, en los últimos días de vida, como parte de una estrategia asistencial de sedación paliativa terminal. Métodos: Se realizó un estudio retrospectivo y descriptivo de 30 pacientes tratados en el Servicio de Oncología del Hospital Hermanos Ameijeiras, desde agosto de 2007 hasta diciembre de 2010, todos tenían confirmación histológica de cáncer y síntomas refractarios en etapa terminal de su enfermedad, edad ³ 18 años y expectativa de vida menor de 2 sem. Previamente se obtuvo el consentimiento del paciente y/o familiares para la indicación del clorhidrato de midazolam (10 mg). Las dosis, formas y vías de administración fueron variables y dependieron de la severidad de los síntomas, experiencia del médico responsable del caso y preferencias de pacientes y/o familiares. Resultados: La disnea y la agitación fueron los síntomas refractarios más frecuentes, mientras que 12 pacientes presentaron 2 o más síntomas. La vía subcutánea fue la más empleada y en más del 70 por ciento de los pacientes se utilizó la forma de administración intermitente. El tiempo de supervivencia, luego de la administración del fármaco, fue de 56,7 por ciento a las 48 h y 5 pacientes tuvieron una supervivencia de 4 d. El rango de dosis utilizado fue de 10-60 mg/d de midazolam. Las dosis más bajas se utilizaron cuando predominaron los síntomas de ansiedad, menor número de síntomas refractarios, la vía subcutánea, y la administración domiciliaria. Conclusiones: La sedación paliativa terminal con midazolam responde a la necesidad clínica de controlar una situación sintomática intolerable con una respuesta eficaz y su administración es segura. Este constituye el primer reporte de utilización de un medicamento para sedación paliativa terminal en pacientes con cáncer en nuestro país

Objective: To describe the use of midazolam in cancer patients during the last days of life, as part of an assistance strategy of terminal palliative sedation. Methods: A retrospective and descriptive study was conducted in 30 patients treated in the Oncology Service of the Hermanos Ameijeiras Clinical Surgical Hospital from August, 2007 to december, 2010 with a histological diagnosis of cancer and refractory symptoms in terminal stage of disease, aged ³ 18 and a life expentancy less than 2 weeks. Previously, the write informed consent was obtained from patient and/or relatives for the prescription of midazolam hydrochloride (10 mg). Doses, ways and routes of administration were variable and in dependence of severity of symptoms, experience of physician responsible of the case and preferences of patients and/or relatives. Results: Dyspnea and agitation were the more frequent refractory symptoms, whereas 12 patients showed two or more symptoms. The subcutaneous route was the more used and in more than 70 percent of patients the drug intermittent way of administration was the used one. Survival time, after the drug administration was of 56,7 percent at 48 h and 5 patients had a survival of 4 days. The dose rank used was that of 10-60 mg/d in the case of midazolam. The lowest doses were used when there was predominance of anxiety symptoms, less refractory symptoms, the subcutaneous route and home administration. Conclusions: The terminal palliative sedation using midazolam account for the clinical need of controlling a intolerable symptomatic situation with an effective response and its administration is safe. This is the first report on the use of a drug for terminal palliative sedation in cancer patients in our country