Sedation indicated?-rethinking existential suffering: a narrative review.

BACKGROUND AND OBJECTIVE: The indication "existential suffering (ES)" for palliative sedation therapy is included in most frameworks for palliative sedation and has been controversially discussed for decades. The appellative character of ES demands rapid relief and sedation often appears to be the best or only solution. ES is still poorly understood and so often neglected by health care professionals due to a lack of consensus regarding assessment, definition and treatment in the international medical literature. Based on a selective review of the literature on ES we propose a different view on the underlying processes of ES and the resulting consequences on medical treatment. METHODS: A narrative review was performed after PubMed search using key terms related to ES and sedation, covering the period from 1950 to April 2023, additionally a selective search in specialist literature on Existential Analysis. Reverse and forward snowballing followed. The language of analyzed publications was restricted to English and German. KEY CONTENT AND FINDINGS: ES is a multidimensional experience that tends to turn into despair and ultimately into a wish to die due to perceived hopelessness and meaninglessness. Pharmacological treatment or sedation do not meet the holistic needs of existential sufferers. The risk of harmful effects by continuous deep sedation seems to be significantly increased for existentially suffering patients. Professional caregivers are burdened by the appellative character of ES, limited treatment options and perceived empathic distress. Without a holistic understanding of the human condition in palliative care, ES cannot be fundamentally alleviated, and existential sufferers have no opportunity to transform and thus mitigate their condition. The recognition of underlying causes of suffering-moods is facilitated by the comprehensive approach of Existential Analysis. CONCLUSIONS: The presented concept of Existential Analysis and the triad of ES are useful instruments for health care professionals to recognize and support underlying moods of existentially suffering patients. Further studies are required. Comprehensive training for professional caregivers on ES is essential to enable them to reflect on their own existential concerns and finiteness as well as those of patients. Continuous deep sedation for ES must remain the exception, equivalent to a last resort option.

[Voluntary stopping eating and drinking (VSED) : A position paper of the Austrian Palliative Society]. / Freiwilliger Verzicht auf Nahrung und Flüssigkeit um das Sterben zu beschleunigen : Eine Stellungnahme der österreichischen Palliativgesellschaft (OPG).

In some cases terminally ill patients fear of prolonged dying and suffering can manifest itself in the voluntary refusal of food and fluids, aiming to accelerate the dying process. This represents a considerable area of conflict, because of the ethical responsibility to not aid a person's death but also to respect a patients autonomy.There is a clear separation between an assisted suicide and following a patient's wishes. Not to accept the voluntary refusal of FVNF would have to be considered as forced treatment of patients while they are capable of self-determination.Several symptoms associated with or caused by voluntary refusal of food and fluids do require palliative care. It is important to be aware, that caring for dying patients refusing food and fluids and accepting their choice is not synonymous with assisted suicide. Rather is it part of medical and nursing care for patients during their dying-process.An interprofessional working group of the Austrian Palliative Society (OPG) intends to shed light on the legal, ethical, medical and nursing related aspects concerning this subject of growing public and professional interest.

Systematic development and adjustment of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE).

BACKGROUND: The Supportive and Palliative Care Indicators tool (SPICT) supports the identification of patients with potential palliative care (PC) needs. An Austrian-German expert group translated SPICT into German (SPICT-DE) in 2014. The aim of this study was the systematic development, refinement, and testing of SPICT-DE for its application in primary care (general practice). METHODS: SPICT-DE was developed by a multiprofessional research team according to the TRAPD model: translation, review, adjudication, pretesting and documentation. In a pretest, five general practitioners (GPs) rated four case vignettes of patients with different PC needs. GPs were asked to assess whether each patient might benefit from PC or not (I) based on their subjective appraisal ("usual practice") and (II) by using SPICT-DE. After further refinement, two focus groups with 28 GPs (68% with a further qualification in PC) were conducted to test SPICT-DE. Again, participants rated two selected case vignettes (I) based on their subjective appraisal and (II) by using SPICT-DE. Afterwards, participants reflected the suitability of SPICT-DE for use in their daily practice routine within the German primary care system. Quantitative data were analysed with descriptive statistics and non-parametric tests for small samples. Qualitative data were analysed by conventional content analysis. Focus group discussion was analysed combining formal and conventional content analysis. RESULTS: Compared to the spontaneous rating of the case vignettes based on subjective appraisal, participants in both the pretest and the focus groups considered PC more often as being beneficial for the patients described in the case vignettes when using SPICT-DE. Participants in the focus groups agreed that SPICT-DE includes all relevant indicators necessary for an adequate clinical identification of patients who might benefit from PC. CONCLUSIONS: SPICT-DE supports the identification of patients who might benefit from PC and seems suitable for routine application in general practice in Germany. The systematic development, refinement, and testing of SPICT-DE in this study was successfully completed by using a multiprofessional and participatory approach.

[Austrian guideline for palliative sedation therapy (long version) : Results of a Delphi process of the Austrian Palliative Society (OPG)]. / Leitlinie zur Palliativen Sedierungstherapie (Langversion) : Ergebnisse eines Delphiprozesses der Österreichischen Palliativgesellschaft (OPG).

BACKGROUND: Palliative sedation therapy (PST) is an important and ethically accepted therapy in the care of selected palliative care patients with otherwise unbearable suffering from refractory distress. PST is increasingly used in end-of-life care. Austria does not have a standardized ethical guideline for this exceptional practice near end of life, but there is evidence that practice varies throughout the country. OBJECTIVE: The Austrian Palliative Society (OPG) nominated a multidisciplinary working group of 16 palliative care experts and ethicists who established the national guideline on the basis of recent review work with the aim to adhere to the Europeans Association of Palliative Care's (EAPC) framework on palliative sedation therapy respecting Austrians legal, structural and cultural background. METHODS: Consensus was achieved by a four-step sequential Delphi process. The Delphi-process was strictly orientated to the recently published EUROIMPACT-sedation-study-checklist and to the AGREE-2-tool. Additionally national stakeholders participated in the reflection of the results. RESULTS: As a result of a rigorous consensus process the long version of the Austrian National Palliative Sedation Guideline contains 112 statements within eleven domains and is supplemented by a philosophers excursus on suffering. CONCLUSIONS: By establishing a national guideline for palliative sedation therapy using the Delphi technique for consensus and stakeholder involvement the Austrian Palliative Society aims to ensure nationwide good practice of palliative sedation therapy. Screening for the practicability and efficacy of this guideline will be a future task.

The Palliative Treatment Plan as a Bone of Contention between Attending Physicians and Nurses.

Acute vital crisis in end-of-life situations may result in hospitalization and intensive care without recognizable benefit in many cases. Advance directives regarding indications for resuscitation, hospitalization, and symptomatic treatment help ensure that acute complications can be managed quickly and satisfactorily in the patient's customary surroundings. A plan was designed and implemented in Austrian nursing homes to provide emergency physicians with rapidly obtainable information on the patient's current situation, and whether resuscitation attempts and hospitalization are advised or not. This palliative treatment plan is arranged by a physician together with caregivers, close relatives, and the patient or his court-appointed health care guardian or holder of power of attorney. Four years after implementation of the plan, a user satisfaction survey was carried out. The majority of participating nurses, emergency physicians and family doctors judged application and design of the palliative treatment plan positively. However, the low response rate of family doctors indicates nonconformity. In particular, the delegation of symptomatic treatment to nurses proved to be controversial. There is still a need to provide up-to-date information and training for health professionals in order for them to understand advance directives as extended autonomy for patients who have lost their ability to make their own decisions.

[The palliative treatment plan as basis for informed decisions in palliative or emergency care]. / Der palliative Behandlungsplan als Entscheidungsbasis zwischen palliativer und notfallmedizinischer Behandlung.

Acute vital crisis in end-of-life situations may result in a person being hospitalized and thus, expelled from his intimate environment, which aggravates the continuity of care. This entails a heavy burden for patients and necessitates an emergency medical services (EMS) call without recognizable benefit in many cases. Crisis episodes frequently mark the beginning of the dying process. Advance care planning or end-of-life care in elderly patients can help prevent such situations and ensure high contentment of patients, families and caregivers. Frequently, the question arises whether the burden arising from further hospitalization or from certain medical treatment options is reasonably balanced by the potential benefits of the steps taken. In such comprehensive care settings a custom-tailored palliative treatment plan may serve as an instrument for advance care planning. A palliative treatment plan set up by a physician together with a caregiver helps ensure that acute problems can be solved quickly and satisfactorily in the patient's customary surroundings. If EMS assistance is still needed, the emergency physician has written information on the patient's situation and can act quickly to meet the patient's immediate needs. This also means that EMS personnel must be properly trained in providing palliative care. In this way the palliative treatment plan can help caregivers continue to care for patients in their intimate surroundings.