Factors that facilitate or constrain the use of continuous sedation at the end of life by physicians and nurses in Belgium: results from a focus group study

Abstract

Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this 'paradigm case' was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.

The impact of the inpatient practice of continuous deep sedation until death on healthcare professionals’ emotional well-being: a systematic review

“…This indicates that there is a lack of a common understanding about the mechanism of how the practice of CDS is related to healthcare professionals’ emotional well-being. Raus et al [27] have shown that the emotional impact of being involved in CDS depends on different dimensions of closeness, defined as the degree to which healthcare professionals feel responsible for CDS decisions or administration [28]. Accordingly, the risk for CDS-related burden is related to professionals’ perceived closeness in CDS decisions, their emotional and physical closeness to the patient, and their perceived causal closeness [28].…”

“…There is evidence that healthcare professionals’ experience with the practice of CDS is particularly positive when decisions are made in a team involving patients and the family [47–50]. Recent findings have confirmed that the process of multidisciplinary decision-making aids professionals dealing with the CDS practice by reducing its emotional impact through shared responsibility [27]. As a source of emotional support an effective team approach can even protect palliative care professionals from burnout [14, 51–53].…”

“…Besides clinical indications, the decision to start CDS is guided by personal wishes of individual patients and families as well as physicians’ experience and values [27–29]. However, engaging the family involves managing the emotional context of families and patients coping with suffering [28].…”

Moral concerns with sedation at the end of life

“…Two studies reported in the Journal of Medical Ethics add to the growing body of qualitative evidence relating to the use of sedatives at the end of life 1 2. Respondents in the two studies affirm a number of important concerns, most of which have been elaborated in the philosophy and palliative care literature, relating to the use of sedation.…”

“…However, there are at least two further distinct categories of use of sedative drugs in dying patients with, naturally, some overlap between all three categories. The second category (which is the explicit focus of the paper by Raus et al 2) is continuous sedation to unconsciousness, with the aim that the patient remains unconscious until she dies. If the sedation starts early enough in the course of the patient's illness, and if nutrition and hydration are withheld, death is clearly going to be hastened.…”