“Suffering” in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice

Bozzaro, Claudia; Schildmann, Jan

doi:10.1016/j.jpainsymman.2018.04.003

Cited by 17 publications

(9 citation statements)

References 18 publications

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“…Today it is not clear what 'unbearable suffering' means and when a symptom is considered refractory, particularly in case of existential suffering. [29][30][31] The observation that pain was associated with the use of continuous deep sedation furthermore might explain the age differences we found. Although older patients seem more likely to experience unbearable pain symptoms, previous studies have shown that younger hospitalized patients are more likely to report pain and more likely to receive pain medication.…”

Section: Discussionmentioning

confidence: 94%

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

et al. 2018

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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.

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Section: Discussionmentioning

confidence: 94%

“…Today it is not clear what ‘unbearable suffering’ means and when a symptom is considered refractory, particularly in case of existential suffering. 29–31…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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“…What are the moral claims of intolerable suffering? [ 4 ]. Bozzaro and Shildmann [ 4 ] argued that the answers to these questions are determined by the underlying assumptions about the nature of suffering.…”

Section: Introductionmentioning

confidence: 99%

“…[ 4 ]. Bozzaro and Shildmann [ 4 ] argued that the answers to these questions are determined by the underlying assumptions about the nature of suffering. They distinguished two typologies of suffering that form these underlying assumptions: a subjective/holistic one informed by the work of Cassell [ 5 ] and an objective/gradual one informed by the work of van Hooft [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

What’s suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

et al. 2021

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Background Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses’ perspectives. Methods A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent. Results Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying. Conclusions Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices.

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“…The complex nature of existential suffering (ES)4–7 continues to fuel the controversy about whether it is a main indication for PS or not (especially if physical pain is under control) 8–10. Distinguishing kinds of suffering is problematic in itself, and objective or subjective assessment of different kinds of suffering is a hotly debated topic in the medical literature 11. The definition of ES is elusive, because the boundaries between it and other kinds of suffering (psychological, social and spiritual) are blurred 12.…”

Section: Introductionmentioning

confidence: 99%

Physicians’ perceptions of palliative sedation for existential suffering: a systematic review

Rodrigues

Menten

Gastmans

2019

BMJ Support Palliat Care

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BackgroundPalliative sedation for existential suffering (PS-ES) is a controversial clinical intervention. Empirical studies about physicians’ perceptions do not converge in a clear position and current clinical practice guidelines do not agree either regarding this kind of intervention.AimTo gain deeper insight into physicians’ perceptions of PS-ES, the factors influencing it, the conditions for implementing it and the alternatives to it.DesignSystematic review of qualitative, quantitative and mixed-methods studies following the Peer Review Electronic Search Strategies and Preferred Reporting Items for Systematic Reviews and Meta-analyses protocols; quality appraisal and thematic synthesis methodology.Data sourcesSeven electronic databases (PubMed, CINAHL, Embase, Scopus, Web of Science, PsycINFO, PsycARTICLES) were exhaustively searched from inception through March 2019. Two reviewers screened paper titles, abstracts and full texts. We included only peer-reviewed journal articles published in English, French, German, Dutch, Spanish, Italian or Portuguese that focused on physicians’ perceptions of PS-ES.ResultsThe search yielded 17 publications published between 2002 and 2017. Physicians do not hold clear views or agree if and when PS-ES is appropriate. Case-related and individual-related factors that influenced physicians’ perceptions were identified. There is still no consensus regarding criteria to distinguish between necessary and sufficient conditions for invoking PS-ES. Some alternatives to PS-ES were identified.ConclusionsTo date, there is still no consensus on physicians’ perceptions of PS-ES. Further research is necessary to understand factors that influence physicians’ perceptions and philosophical-ethical presuppositions underlying this perceptions.

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“Suffering” in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice

Cited by 17 publications

References 18 publications

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

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

What’s suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

Physicians’ perceptions of palliative sedation for existential suffering: a systematic review

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