Sedatives and Sedation at the End of Life in the Hospital

Overview

Journal Dtsch Arztebl Int

Specialties General Medicine
Public Health

Date 2022 Apr 20

PMID 35440363

Authors

Eva Schildmann

Sophie Meesters

Claudia Bausewein

Affiliations

Soon will be listed here.

Abstract

Background: Data on sedation at the end of life (eol) in different medical disciplines are scarce and mostly based on subjective reports. We aimed to assess the use of sedatives with continuous effect in the last week of life and associated factors in different hospital departments, with the aid of objectifiable criteria.

Methods: We conducted a retrospective cohort study based on the medical records of patients who died in one of five clinical departments of German hospitals between January 2015 and December 2017 (hematology/oncology [two different departments], neurology, geriatrics, and gynecology). The use of sedatives that are recommended in guidelines for palliative sedation was analyzed, irrespective of indication and treatment intent, with the aid of published definitions of continuous effect and of at least moderately sedating doses. The analysis consisted of descriptive statistics and multivariate logistic regression analysis.

Results: 260/517 (50%) of the patients who died were given sedatives with continuous effect in the last week of life, 53/517 (10%) in at least moderately sedating doses. For 76/260 (29%) patients, no indication was noted. The term "sedation" was used in the medical records of 20/260 (8%) patients. The use of sedatives with continuous effect was significantly associated with the department in which the patient was treated (hematology/oncology II: OR 0.32, 95% CI [0.16: 0.63]; geriatrics: OR 0.23, 95% CI [0.10:0.50]; reference, hematology/oncology I).

Conclusion: It was not possible to draw a clear distinction between the use of sedatives for symptom control, without sedating effect or intent to sedate, and intentional sedation to relieve suffering. The observed differences between hospital departments and deviations from recommended practice, e.g. lack of documentation of the indication, warrant further exploration. Moreover, context-specific supportive measures for the use of sedatives and sedation at the end of life should be developed.

Citing Articles

Palliative sedation at the end of life: prevalence, characteristics and possible determinants.

Carrasco-Zafra M, Ocana-Riola R, Gomez-Garcia R, Martin-Rosello M, Blanco-Reina E BMC Palliat Care. 2024; 23(1):278.

PMID: 39639319 PMC: 11622477. DOI: 10.1186/s12904-024-01606-0.

Sedation in Palliative Care—a Clinically Oriented Overview of Guidelines and Treatment Recommendations.

Klein C, Voss R, Ostgathe C, Schildmann J Dtsch Arztebl Int. 2023; 120(14):235-242.

PMID: 36851822 PMC: 10282508. DOI: 10.3238/arztebl.m2023.0034.

Palliative Sedation: Controversial Discussions and Appropriate Practice.

Alt-Epping B Dtsch Arztebl Int. 2022; 119(21):371-372.

PMID: 36045550 PMC: 9487709. DOI: 10.3238/arztebl.m2022.0212.

References

Schildmann E, Schildmann J . Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making. J Palliat Med. 2014; 17(5):601-11. DOI: 10.1089/jpm.2013.0511. View

Jansen A, Van Aalst-Cohen E, Hutten B, Buller H, Kastelein J, Prins M . Guidelines were developed for data collection from medical records for use in retrospective analyses. J Clin Epidemiol. 2005; 58(3):269-74. DOI: 10.1016/j.jclinepi.2004.07.006. View

Gurschick L, Mayer D, Hanson L . Palliative Sedation: An Analysis of International Guidelines and Position Statements. Am J Hosp Palliat Care. 2014; 32(6):660-71. DOI: 10.1177/1049909114533002. View

Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F . Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol. 2012; 30(12):1378-83. DOI: 10.1200/JCO.2011.37.3795. View

Grune B, Meesters S, Bausewein C, Schildmann E . Challenges and Strategies Regarding Sedation at the End of Life in Hospitals and Nursing Homes. J Pain Symptom Manage. 2021; 63(4):530-538. DOI: 10.1016/j.jpainsymman.2021.12.012. View

Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan M . Continuous Deep Sedation Until Death-a Swiss Death Certificate Study. J Gen Intern Med. 2018; 33(7):1052-1059. PMC: 6025678. DOI: 10.1007/s11606-018-4401-2. View

de Graeff A, Dean M . Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med. 2007; 10(1):67-85. DOI: 10.1089/jpm.2006.0139. View

Papavasiliou E, Brearley S, Seymour J, Brown J, Payne S . From sedation to continuous sedation until death: how has the conceptual basis of sedation in end-of-life care changed over time?. J Pain Symptom Manage. 2013; 46(5):691-706. DOI: 10.1016/j.jpainsymman.2012.11.008. View

Beller E, Van Driel M, McGregor L, Truong S, Mitchell G . Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev. 2015; 1:CD010206. PMC: 6464857. DOI: 10.1002/14651858.CD010206.pub2. View

10.

Stephenson J . The use of sedative drugs at the end of life in a UK hospice. Palliat Med. 2008; 22(8):969-70. DOI: 10.1177/0269216308098801. View

11.

Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan M . Using sedative substances until death: A mortality follow-back study on the role of healthcare settings. Palliat Med. 2018; 33(2):213-220. DOI: 10.1177/0269216318815799. View

12.

Raus K, Sterckx S . How defining clinical practices may influence their evaluation: the case of continuous sedation at the end of life. J Eval Clin Pract. 2015; 22(3):425-32. DOI: 10.1111/jep.12503. View

13.

Twycross R . Reflections on palliative sedation. Palliat Care. 2019; 12:1178224218823511. PMC: 6350160. DOI: 10.1177/1178224218823511. View

14.

Morita T . Differences in physician-reported practice in palliative sedation therapy. Support Care Cancer. 2004; 12(8):584-92. DOI: 10.1007/s00520-004-0603-8. View

15.

Meesters S, Grune B, Bausewein C, Schildmann E . "We don't want to sedate him" - A qualitative interview study on intentions when administering sedative drugs at the end of life in nursing homes and hospitals. BMC Palliat Care. 2021; 20(1):141. PMC: 8439055. DOI: 10.1186/s12904-021-00832-0. View

16.

Kremling A, Schildmann J . What do you mean by "palliative sedation"? : Pre-explicative analyses as preliminary steps towards better definitions. BMC Palliat Care. 2020; 19(1):147. PMC: 7513316. DOI: 10.1186/s12904-020-00635-9. View

17.

Schildmann E, Schildmann J, Kiesewetter I . Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manage. 2014; 49(4):734-46. DOI: 10.1016/j.jpainsymman.2014.08.013. View

18.

Klosa P, Klein C, Heckel M, Bronnhuber A, Ostgathe C, Stiel S . The EAPC framework on palliative sedation and clinical practice--a questionnaire-based survey in Germany. Support Care Cancer. 2014; 22(10):2621-8. DOI: 10.1007/s00520-014-2192-5. View

19.

Anquinet L, Raus K, Sterckx S, Smets T, Deliens L, Rietjens J . Similarities and differences between continuous sedation until death and euthanasia - professional caregivers' attitudes and experiences: a focus group study. Palliat Med. 2012; 27(6):553-61. DOI: 10.1177/0269216312462272. View

20.

Schildmann E, Meesters S, Grune B, Bolzani A, Habboub B, Hermann A . Sedatives and Sedation at the End of Life in Nursing Homes: A Retrospective Multicenter Cohort Study. J Am Med Dir Assoc. 2020; 22(1):109-116.e1. DOI: 10.1016/j.jamda.2020.08.019. View