Deep continuous patient-requested sedation until death: a multicentric study

Abstract

ObjectivesIn 2016, a new law was adopted in France granting patients the right, under specific conditions, to continuous deep sedation until death (CDSUD). The goal of this study was to measure the frequency of requests for CDSUD from patients in palliative care.MethodsThe data collected from the medical records of patients in palliative care units (PCU) or followed by palliative care support teams (PCST) in the Rhône-Alpes area, who died after CDSUD, focused on the patient’s characteristics, the drugs used (and compliance with regulatory processes).ResultsAll 12 PCU and 12 of the 24 PCST were included. Among the 8500 patients followed, 42 (0.5%) requested CDSUD until death. The patients were: 65.7 (SD=13.7) years old, highly educated (69%), had cancer (81%), refractory symptoms (98%) and mostly psychoexistential distress (69%). The request was rejected for 2 (5%) patients and delayed for 31 (74%) patients. After a delay of a mean 8 days, 13 (31%) patients were granted CDSUD. The drug used was midazolam at 115 mg/24 hours (15–480), during a mean of 3 days. PCUs used lower dosages than PCSTs (83 vs 147), with significantly lower initial doses (39 mg vs 132 mg, p=0.01). A life-threatening condition was recorded in 13 cases (31%) and a collegial decision was taken in 25 cases (60%).ConclusionThis study highlights the low rate of request and the even lower rate of CDSUD in specialised palliative care. However, the sedation for psychoexistential distress and the lack of procedure records raise ethical questions.

Clinical and ethical aspects of palliative sedation with propofol—A retrospective quantitative and qualitative study

“…Physicians are likely to be influenced by their tradition's emphasis on additional diagnostic tests and procedures, an approach which is more meaningful in potential curative conditions. Even though the palliative approach at the end of life strongly emphasizes pain relief, the present study indicates that even at a palliative ward there might be delays in instigating necessary measures to relieve suffering 16 …”

Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective

“…Since 2016, in France, mainly case reports are available about CDSUD practices and health care professionals' feelings (De Nonneville et al, 2016; Boulanger et al, 2017; Plançon et al, 2018; Vitale et al, 2019). Larger studies, including multicentric surveys (Serey et al, 2019) should be developed in the future to better understand indications and consequences on clinical practices.…”

“…Despite the obvious need for knowledge on the topic, continuous palliative sedation and CDSUD are understudied as appropriate responses to refractory existential distress, and they are relatively underused in clinical practice. Recently, a French study of 8500 patients either followed in palliative care units or palliative care support teams, found that only 0.5% of them requested CDSUD, mostly for psycho-existential distress (69%) (Serey et al, 2019). A Canadian survey of 322 palliative care physicians (response rate of 26%) found that 31% reported providing continuous palliative sedation in cases of existential distress alone.…”

Controlling Death. Highlights from Harvard Medical School Annual Bioethics Conference

“…Medication is installed in a dosage to achieve unresponsiveness and remains until patient's death. "Continuous sedation until death at the patient's request is obviously different from palliative sedation" (Serey, 2019). Interpreting Twycross (2019), as the patient is unconscious, he cannot eat or drink by mouth, and this may lead to hasten death -biological life; also, PSU ends a person's ability to interact -biographical life.…”

“…One may question whats is the difference between PSU and euthanasia. According to Serey (2019), it is based on the sedative drug dosage and on prescriber's intentionality. It is still controversial in the literature if PSU indeed hasten death, as expressed by Serey (2019) multicentric study.…”