Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE

Krooupa, Anna-Maria; Vivat, Bella; McKeever, Stephen; Marcus, Elena; Sawyer, Joseph M; Stone, Patrick

doi:10.1177/0269216319871666

Cited by 20 publications

(20 citation statements)

References 105 publications

(317 reference statements)

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“… 71 Existential distress has been linked to aspects such as loss of personal meaning and purpose to life, fear of death, despair, hopelessness, loss of dignity, sense of isolation. 72 , 73 No instruments were reported in the included articles. However, a review on available instruments to assess suffering for use in palliative care has identified instruments for assessing psycho-existential suffering.…”

Section: Discussionmentioning

confidence: 99%

“… 39 The RASS-PAL has received the highest rating on psychometric properties together with the Consciousness Scale for Palliative Care, according to a recent systematic review evaluating instruments to monitor level of consciousness on palliative patients. 73 The other two instruments identified in the current review and validated for palliative care are the KNMG sedation score of the Royal Dutch Medical Association 62 and the Consciousness Scale for Palliative care. 8 The former being mainly used in Dutch contexts and the latter reported as easy to use.…”

Section: Discussionmentioning

confidence: 99%

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How to measure the effects and potential adverse events of palliative sedation? An integrative review

et al. 2020

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Background: Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed. Aim: To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured. Design: Integrative review of most recent empirical research. Data sources: Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010–2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness. Results: Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agitation-Sedation Scale and The Ramsay Sedation Scale are the most used to measure its effect. Refractory symptoms were assessed through multi-symptom or specific scales; except for psychological or existential distress. Delirium was assessed using the Memorial Delirium Assessment Scale and pain through the Critical Care Pain Observation Tool. The use of technical approaches to monitor effects is upcoming. There is lack of measurement of possible adverse events and variability in timing measurement. Conclusions: There are palliative care validated instruments to assess the sedation effect but this review shows the need for a more standardized approach when assessing it. Instruments should be used within an experienced and trained expert, providing a holistic assessment.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

How to measure the effects and potential adverse events of palliative sedation? An integrative review

et al. 2020

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“…22 Non-stimulating and non-invasive monitoring (including processed, electroencephalogram-based depth of sedation devices and nociception monitoring) could allow a more objective and frequent assessment of the levels of consciousness and analgesia during palliative sedation compared to clinical scales. 23,24 Depth of sedation monitoring tools such as the Bispectral Index (BIS), Entropy, and NeuroSense, have been used to monitor anesthesia and sedation, with the aims of decreasing the incidence of intraoperative awareness and reducing both anesthetic consumption and recovery time. [25][26][27] For this method, a disposable wet gel electrode is placed on the patient's forehead to record electric signals from the cortex and transfer them to a digital converter.…”

Section: Introductionmentioning

confidence: 99%

“…Non-stimulating and non-invasive monitoring (including processed, electroencephalogram-based depth of sedation devices and nociception monitoring) could allow a more objective and frequent assessment of the levels of consciousness and analgesia during palliative sedation compared to clinical scales. 23,24…”

Section: Introductionmentioning

confidence: 99%

Monitoring nociception and awareness during palliative sedation: A systematic review

Dieudonné-Rahm¹,

Morawska²,

Pautex³

et al. 2021

Palliat Med

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Background: Providing unawareness and pain relief are core elements of palliative sedation. In addition to clinical scales, nociception and electroencephalogram-based depth of sedation monitoring are used to assess the level of consciousness and analgesia during sedation in intensive care units and during procedures. Aim: To determine whether reported devices impact the outcomes of palliative sedation. Design: Systematic review and narrative synthesis of research published between January 2000 and December 2020. Data sources: Embase, Google Scholar, PubMed, CENTRAL, and the Cochrane Library. All reports describing the use of any monitoring device to assess the level of consciousness or analgesia during palliative sedation were screened for inclusion. Data concerning safety and efficacy were extracted. Patient comfort was the primary outcome of interest. Articles reporting sedation but that did not meet guidelines of the European Association for Palliative Care were excluded. Results: Six reports of five studies were identified. Four of these were case series and two were case reports. Together, these six reports involved a total of 67 sedated adults. Methodological quality was assessed fair to good. Medication regimens were adjusted to bispectral index monitoring values in two studies, which found poor correlation between monitoring values and observational scores. In another study, high nociception index values, representing absence of pain, were used to detect opioid overdosing. Relatives and caregivers found the procedures feasible and acceptable.

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“…To assess the level of comfort of these unconscious patients, usually subjective behavior-based observational scales are used. However, a number of studies have recently questioned the accuracy and validity of such scales in these situations [3]. Although several efforts have been made to improve these observational scales for the palliative patient group, the main problem with observational assessment methods for palliatively sedated patients is related to the medication itself.…”

Section: Introductionmentioning

confidence: 99%

Neurophysiological Assessments During Continuous Sedation Until Death Put Validity of Observational Assessments Into Question: A Prospective Observational Study

et al. 2020

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Introduction: In case of untreatable suffering at the end of life, continuous sedation until death (CSD) may be the only treatment option left. Because these patients cannot communicate anymore, caregivers have to rely on behavioral observation to assess the patient's comfort. Recently, however, a number of studies from the neurosciences have shown that sometimes consciousness and pain are undetectable with these traditional behavioral methods. The aim of this study was to find out if subjective caregiver assessments of consciousness and pain would be confirmed by objective neurophysiological measures. Methods: In this prospective observational study, we observed patients from the start of palliative sedation until death. Subjective caregiver assessments of level of consciousness and pain based on behavioral observations were compared with objective measures from neurophysiological monitoring devices. Results: We collected and analyzed 108 subjective caregiver assessments in a sample of 12 patients and 32 assessments by traditionally used observational scales. We compared these with objective neurophysiological measures. Sensitivity and specificity of caregivers' subjective assessments of consciousness was 23.6 and 91.1% respectively, with an accuracy of 54.0% and interrater reliability (j) of 0.13. For pain, this was 0 and 94.79%, respectively, an accuracy of 88%, and an inter-rater reliability (j) of-0.063. Agreement between caregivers' subjective assessments and objective neurophysiological measures of consciousness and pain was very poor. Conclusions: Caregivers' subjective assessment of level of consciousness and pain during CSD is unreliable compared with objective neurophysiological monitoring. Our results suggest that assessments of patient comfort during CSD could have been improved substantially by including objective monitoring of level of consciousness and pain.

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Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE

Cited by 20 publications

References 105 publications

How to measure the effects and potential adverse events of palliative sedation? An integrative review

How to measure the effects and potential adverse events of palliative sedation? An integrative review

Monitoring nociception and awareness during palliative sedation: A systematic review

Neurophysiological Assessments During Continuous Sedation Until Death Put Validity of Observational Assessments Into Question: A Prospective Observational Study

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