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

Schildmann, Eva; Meesters, Sophie; Grüne, Bettina; Bolzani, Anna; Habboub, Basel; Hermann, Alina; Rémi, Constanze; Bausewein, Claudia

doi:10.1016/j.jamda.2020.08.019

Cited by 11 publications

(17 citation statements)

References 38 publications

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“…Healthcare professionals who do not perceive and label their treatment as ‘sedation’ will not refer to respective guidelines, even if they are aware of them. This may be one of the reasons for deviations from guidelines regarding sedation, which have been reported particularly for the general palliative care setting, for example regarding indications, processes of decision-making and choice of drugs – including the use of opioids for sedation [ 17 , 18 , 24 ].…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, previous data indicate that particularly in general palliative care settings, drugs other than the ones recommended in guidelines are used to reduce a patient’s consciousness at the end of life [ 16 , 17 ]. The quantitative part of this mixed-methods study revealed that administration of sedative drugs was never labelled as ‘sedation’ in the documents of the participating nursing homes [ 18 ]. Given these cultural and setting-specific differences, this study aimed to explore the concept of ‘sedative drugs’ and the intentions of German healthcare professionals in general palliative care when administering sedative drugs at the end of life.…”

Section: Introductionmentioning

confidence: 99%

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“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

et al. 2021

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Background Previous data indicate major differences between countries and settings regarding the intention when administering sedative drugs at the end of life and the perception, which drugs are sedating. Therefore, we aimed to explore the concept of ‘sedative drugs’ and the intentions of German healthcare professionals in general palliative care when administering sedative drugs at the end of life. Methods Semi-structured qualitative interviews with physicians and nurses (n = 49). Recruitment took place via contact persons in five hospital departments (haematology/oncology (n = 2), neurology, geriatrics, gynaecology) and five nursing homes. We thematically analysed the transcripts by the Framework approach, using MAXQDA version 2018.2. Results Most interviewees referred to benzodiazepines, opioids, and antipsychotics. Some subsumed all into sedative drugs, others differentiated between sedative drugs, anxiolytics, and analgesics. In explaining their intention, interviewees particularly emphasized what they want to avoid when administering sedative drugs. We identified three main themes regarding (excluded) intentions: (1) use of sedative drugs to relieve the patient’s suffering with reduction of consciousness as side effect, (2) use of sedative drugs to relieve the situation for the team and/or the family, (3) distinction between intention and expectation regarding hastening death. Interviewees often equated the term ‘sedation’ with inducing a state of unconsciousness, which should be avoided. Conclusion German healthcare professionals in general palliative care seem to negatively connote the term ‘sedation’. Moreover, they see themselves in a more passive role by accepting a side effect rather than performing an intentional act. Critical reflection of indications and intentions in accordance with respective guidelines is needed.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“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

et al. 2021

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“…The study results must be considered in the context of the following limitations, which have partly been discussed in the previous publication regarding the quantitative phase. 42 To gain a realistic picture of everyday practice, we chose a retrospective design. However, some data have been recorded incompletely, for example, the route of continuous administration (subcutaneous or intravenous) or symptoms.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Section: Strengths and Limitationsmentioning

confidence: 99%

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

et al. 2022

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ObjectivesContinuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments.MethodsIn a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed.ResultsDuring the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for “palliative” patients. According to our interviewees’ views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an “overall-concept” for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions.ConclusionsContinuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a “standard procedure” in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.

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“…32 One example discussed in this month's JAMDA is the use of sedation to relieve severe distress among persons who are dying. 33 A somewhat different issue around individualization involves medications to relieve symptoms and/or increase quality of life. One such category of drugs is recreational agents such as alcohol and marijuana.…”

Section: Need To Better Tailor Prescribing Based On Resident Characteristicsmentioning

confidence: 99%

Medications in Post-Acute and Long-Term Care: Challenges and Controversies

Sloane

Brandt

Cherubini

et al. 2021

Journal of the American Medical Directors Association

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Nursing Homes post-acute care long-term care medications prescribing deprescribing Pharmaceutical agents are a valuable resource to assist in the care of older persons. Their use in post-acute and long-term care settings is particularly notabledfor example, the proportion of nursing home residents taking 9 or more medications increased from 18% in the mid-1990s to 40% less than 15 years later. 1,2 Average drug counts are similarly high around the world, although there is considerable variation in use between settings and countries. 3,4 High medication use occurs despite the fact that persons with advanced age and multimorbidity are particularly susceptible to drug adverse effects due to physiological changes such as declines in hepatic and renal clearance. Further, the probability of deleterious drug interactions rises exponentially as the number of medications increases. 5 Why are so many drugs administered in post-acute and long-term care, and why does the number keep rising? One reason is because new and better agents have been developed for a variety of conditions common in nursing homes, which relieve or prevent morbidity and delay mortality. Many of these newer medications, such as bisphosphonates for fracture prevention, angiotensin-converting enzyme inhibitors for diabetic renal protection, and beta blockers for coronary artery disease, have strong data in the nursing home literature supporting their use. Other reasons for increasing drug lists, however, are less clearly good for patients. In some cases,The authors declare no conflicts of interest.

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

Cited by 11 publications

References 38 publications

“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

“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

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

Medications in Post-Acute and Long-Term Care: Challenges and Controversies

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