Sedatives and sedation at the end of life: a nursing home retrospective cohort study

Abstract

ObjectivesSedatives are frequently used at the end of life in specialist palliative care. There is scarce information about their use in nursing homes. Therefore, we aimed to assess the use of (1) sedatives generally and (2) ‘sedatives with continuous effect’, based on objective operational criteria, within the last week of life in a nursing home.MethodsThis was a retrospective cohort study of residents who died in a German nursing home between 1/2015 and 12/2017, using the nursing home’s medical records, which contained drug sheets and nurses’ notes. Sedatives analysed were those recommended by guidelines for ‘palliative sedation’: benzodiazepines, levomepromazine, haloperidol (≥5 mg/day) and propofol. Exploratory statistical analysis was conducted using R V.3.6.1.Results46/165 (28%) deceased residents received a sedative during the last week of life, all without use of the term ‘sedation’. 26/165 residents (16%) received ‘sedatives with continuous effect’, for median 4 days (range 1–7). Oral lorazepam was used most frequently, mainly for agitation, anxiety and dyspnoea, but also due to palliative status and patients wish. The median total daily dose of lorazepam within the last week of life was 1.5 mg (range 0.5–7.5). The term ‘palliative’ was significantly more often used for residents receiving sedatives (p=0.001).ConclusionsCompared with published data on continuous deep sedation, moderate or deep sedation was less frequent in this nursing home and never labelled as ‘sedation’. Multicentre mixed-methods research is needed to gain representative and more detailed data on sedation practices at the end of life in nursing homes.

Sedatives and Sedation at the End of Life in Nursing Homes: A Retrospective Multicenter Cohort Study

“…These are the first multicenter data on different sedation practices at the end of life in nursing homes, based on previously published objective operational criteria. 27,28 Within the last week of life, about a fifth of all residents received a sedative, about half of these "with continuous effect." Median doses were low, but 2% of residents received "sedatives with continuous effect" in doses judged as at least moderately sedating.…”

“…The definition of "sedatives with continuous effect" of the singlecenter study was used: either continuous parenteral infusion for !0.5 hours or repeated application expected to result in sedation for !24 hours (see Table 1). 27 This definition was based on the literature, including the drugs' prescribing information, and consensus by SPC pharmacists and clinicians. 34 In addition, doses judged as probably at least moderately sedating in this older adult population were consented by SPC pharmacists and clinicians, based on the drugs' prescribing information and other available literature (see Table 1).…”

“…Objective criteria, established in an earlier study, were further complemented for this study to assess the use of sedatives at the end of life independent of its labeling in the medical records. 27 Additionally, measures were taken to maximize consistency and minimize errors in data extraction, as described in the Methods section.…”

“…As also discussed in our single-center study, this is aggravated by the fact that we only had access to the nursing homes' medical records, not to separate records kept by general practitioners and SPC teams. 27 However, we chose this design to gain a realistic picture of everyday practice. A prospective study could have influenced the decisions of the health care team and the documentation of their practice.…”

“Palliative Syringe Driver”? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care

“…Data extraction was guided by a detailed instruction sheet, and 2 researchers jointly extracted data for randomly selected 20% of all records to ensure accuracy. We defined “sedatives” as drugs recommended by guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol ≥5 mg/d (as lower doses are unlikely to be sedating), and propofol 24–28 . Data on the use of sedating drugs (sedatives and opioids) in the last week of life were collected: doses per day, indication, and routes of administration.…”