Abstract
Background
Although palliative sedation therapy is often required in terminally ill cancer patients, little is known about actual practice. The aims of this study were to clarify the physician-reported sedation practices and the factors influencing the sedation rates.
Methods
A questionnaire was sent to 105 representative physicians of all certified palliative care units in Japan. A total of 81 responses were analyzed (effective response rate, 80%).
Results
The prevalence of continuous-deep sedation for physical symptoms was <10% in 33 institutions (41%), 10–50% in 43 institutions (53%), and >50% in 5 institutions (6.2%). The prevalence of continuous-deep sedation for psychoexistential suffering was 0% in 52 institutions (64%), 0.5–5% in 26 institutions (32%) and more than 10% in 3 institutions (3.6%). Continuous-deep sedation was more frequently performed by physicians who did not believe clear consciousness was necessary for a good death, who did not believe that sedation often shortened patient life, who worked with nurses specializing in cancer/palliative care, who judged the symptoms as refractory without actual trials of treatments, who performed continuous sedation first rather than intermittent sedation, and who used phenobarbitones frequently.
Conclusions
Physician-reported practice in palliative sedation therapy varied widely among institutions. The differences were mainly associated with the physicians’ philosophy about a good death, physicians’ belief about the effects of sedation on patient survival, and physicians’ medical practice. Discussion should be focused on these divergent areas, and clear clinical guidelines are urgently needed to provide valid end-of-life care.
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References
Breitbart W, Gibson C, Tremblay A (2002) The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouse/caregivers, and their nurses. Psychosomatics 43:183–194
Bruera E, Franco JJ, Maltoni M, et al (1995) Changing pattern of agitated impaired mental status in patients with advanced cancer: association with cognitive monitoring, hydration, and opioid rotation. J Pain Symptom Manage 10:287–291
Chater S, Viola R, Paterson J, et al (1998) Sedation for intractable distress in the dying—a survey of experts. Palliat Med 12:255–269
Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY (2001) Sedation for refractory symptoms of terminal cancer patients in Taiwan. J Pain Symptom Manage 21:467–472
Cowan JD, Walsh D (2001) Terminal sedation in palliative medicine: definition and review of the literature. Support Care Cancer 9:403–407
de Stoutz ND, Bruera E, Suarez-Almazor M (1995) Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manage 10:378–384
Emanuel El, Fairclough D, Clarridge BC, et al (2000) Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med 133:527–532
Fainsinger RL, Waller A, Bercovici M, et al (2000) A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med 14:257–265
Grassi L, Magnani K, Ercolani M (1999) Attitudes toward euthanasia and physician-assisted suicide among Italian primary care physicians. J Pain Symptom Manage 17:188–196
Howard OM, Fairclough DL, Daniels ER, et al (1997) Physician desire for euthanasia and assisted suicide: would physicians practice what they preach? J Clin Oncol 15:428–432
Jansen LA, Sulmasy DP (2002) Sedation, alimentation, hydration, and equivocation: careful conversation about care at the end of life. Ann Intern Med 136:845–849
Lawlor PG, Ganon B, Mancini IL, et al (2000) Occurrences, causes, and outcome of delirium in patients with advanced cancer. A prospective study. Arch Intern Med 160:786–794
Morita T, Tsunoda J, Inoue S, Chihara S (1999) Do hospice clinicians sedate patients intending to hasten death? J Palliat Care 15:20–23
Morita T, Tsuneto S, Shima Y (2001) Proposed definitions for terminal sedation. Lancet 358:335–336
Morita T, Tsunoda J, Inoue S, et al (2001) Effects of high dose opioid and sedatives on survival in terminally ill cancer patients. J Pain Symptom Manage 21:282–289
Morita T, Akechi T, Sugawara Y, Chihara S, Uchitomi Y (2002) Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: a nationwide survey. J Clin Oncol 20:758–764
Morita T, Tsuneto S, Shima Y (2002) Definition of sedation for symptom relief: a systematic literature review and a proposal of operational criteria. J Pain Symptom Manage 24:447–453
Morita T, Hirai K, Sakaguchi Y, Tsuneto S, Shima Y (2004) Family-perceived distress about delirium-related symptoms of terminally ill cancer patients. Psychosomatics (in press)
Orentlicher D (1998) Dr. Orentlicher replies. N Engl J Med 338:1230–1231
Peruselli C, Giulio PD, Toscani F, et al (1999) Home palliative care for terminal cancer patients: a survey on the final week of life. J Pain Symptom Manage 13:233–241
Portney RK, Coyle N, Kash KM, et al (1997) Determinants of the willingness to endorse assisted suicide. A survey of physicians, nurses, and social workers. Psychosomatics 38:277–287
Quill TE, Lo B, Brock DW (1997) Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 278:2099–2104
Sales JP (2001) Sedation and terminal care. Eur J Palliat Care 8:97–100
Stone P, Phillips C, Spruyt O, et al (1997) A comparison of the use of sedatives in a hospital support team and in a hospice. Palliat Med 11:140–144
Sykes N, Thorns A (2003) Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med 163:341–344
Ventafridda V, Ripamonti C, De Connno F, et al (1990) Symptom prevalence and control during cancer patients’ last days of life. J Palliat Care 6:7–11
Acknowledgements
We would like to express special thanks to Emi An M.D. (Peace House Hospice), Masayuki Ikenaga, M.D. (Hospice, Yodogawa Christian Hospital), Mikako Okada, R.N. (Department of Palliative Care, St. Luke’s International Hospital), Masako Kawa, R.N. (Department of Adult Nursing/Terminal and Long-Term Care Nursing, University of Tokyo), Akira Shimada, M.D., Ph.D. (Department of Palliative Medicine, Tohoku University Hospital), Yukiko Toyoshima, R.N. (Department of Nursing, Seirei Christopher College), Satoru Tsuneto, M.D., Ph.D. (Graduate School of Human Sciences, Osaka University), and Fumio Yamazaki, M.D. (St. John’s Hospice, Sakuramachi Hospital) for construction of the questionnaire.
This study was partially supported by a grant for Improvement of QOL in Terminal Care from the Sasakawa Health Science Foundation.
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Morita, T. Differences in physician-reported practice in palliative sedation therapy. Support Care Cancer 12, 584–592 (2004). https://doi.org/10.1007/s00520-004-0603-8
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DOI: https://doi.org/10.1007/s00520-004-0603-8