Using sedative substances until death: A mortality follow-back study on the role of healthcare settings

Abstract

Background: In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated. Aim: To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control. Design: National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older. Setting/participants: Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included. Results: Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001). Conclusion: In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.

Automated Stereotactic Gamma Ray Radiosurgery to the Pituitary Gland in Terminally Ill Cancer Patients with Opioid Refractory Pain

“…The visual analogue scale (VAS) was nine (7-10) and standardized to 10; eight patients (80%) responded. The average VAS at the time of response was three (range: [1][2][3][4][5][6], and the average time to response was 2.8 days (range: 2-5). In the first week, 40% of the patients categorized the result as 'excellent', 30% deemed the result 'good', and 20% reported the result as 'poor'.…”

“…Refractory pain in cancer patients during their terminal phase is surely underrated worldwide but especially so in geographical settings with limited resources [4][5]. At best, where more efficient health and palliative care is available, patients are mainly managed by opiates that produce sedative states [1] or incur other well-known side effects [21] without necessarily producing an optimal pain control in some patients. Revitalizing well-known noninvasive techniques such as radiosurgical hypophysectomy could align with the palliative armamentarium to improve end-stage quality of life in selected patients.…”

“…Pain derived from cancer represents a heavy burden on patients, their families, and healthcare systems worldwide; even in economically advanced countries, refractory oncological pain is a challenge for palliative care [1][2]. Although there is no strict definition of 'refractory pain', some authors agree that chronic refractory pain in cancer is the persistent physical signs and symptoms associated with phenomena where surgical interventions, radiation, nerve blocks, physiotherapy, and opioids have failed (and are either not feasible or tolerated) [3].…”

“…Although there is no strict definition of 'refractory pain', some authors agree that chronic refractory pain in cancer is the persistent physical signs and symptoms associated with phenomena where surgical interventions, radiation, nerve blocks, physiotherapy, and opioids have failed (and are either not feasible or tolerated) [3]. These are terminally ill patients who are usually bedridden or whose mobility, daily activities, and quality of life are severely impaired directly by pain, sedation [1], or by the side effects caused by pain management treatments. Limited resource settings (as experienced in most of the world) impose a further toll on this set of patients among whom moderate to severe pain has been reported in more than half the population [4][5].…”

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

“…'Sedation in palliative care (PC)’ or ‘palliative sedation’ has been defined as ‘monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering (…)’ 1. While most research on sedation at the end of life focuses on the specialist palliative care (SPC) setting, it is also common practice outside SPC 2–4. A substantial number of people die in nursing homes, and, given the demographic developments, this number will probably increase 3…”