A systematic review of quality improvement initiatives for continuous sedation until death

Abstract

Background: Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. Aim: To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. Design: Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). Data sources: Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. Results: Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. Conclusions: The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.

Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study

“…As the practice of CDS is believed to have room for improvement, various quality improvement initiatives have been developed in the medical field that have had little impact [22]. In accordance with our findings, it is recommended that such initiatives should also address the environmental context of physicians in order to enhance their leverage.…”

“…For example, some practitioners deploy CDS to hasten death in order to mitigate proxies' burden [19]; suboptimal medication is sometimes used to initiate CDS [20]; proxies are often not involved in the decision making about CDS, and they may put practitioners under pressure to induce CDS [9,21]; and practitioners may experience emotional and moral distress throughout CDS practice [9]. Moreover, few quality-improvement initiatives have been successful in addressing these challenges in practice [22], which may indicate poor understanding and underestimation of the importance of the broader context.…”

Ethical challenges in palliative sedation of adults: protocol for a systematic review of current clinical practice guidelines

“…A recent systematic review that is focused on continuous sedation until death explores only the quality improvement initiatives for this practice. 19 As previously noted, there are various forms of palliative sedation. Continuous deep sedation until death (CDSUD), considered 'an extreme facet of end-of-life sedation', 20 is the most controversial, at both the clinical and ethical levels, and is widely explored and debated in the literature.…”

Ethical challenges in palliative sedation of adults: protocol for a systematic review of current clinical practice guidelines

“…A recent systematic review that is focused on continuous sedation until death explores only the quality improvement initiatives for this practice. 19 …”

“…However, the ethical challenges of each form of palliative sedation have not been explored in depth. A recent systematic review that is focused on continuous sedation until death explores only the quality improvement initiatives for this practice 19…”