Livia Anquinet

General practitioners' report of continuous deep sedation until death for patients dying at home: A descriptive study from Belgium

Abstract Background: Palliative sedation is increasingly used at the end of life by general practitioners (GPs). Objectives: To study the characteristics of one type of palliative sedation, ‘continuous deep sedation until death’, for patients dying at home in Belgium. Methods: SENTI-MELC, a large-scale mortality follow-back study of a representative surveillance network of Belgian GPs was conducted in 2005–2006. Out of 415 non-sudden home deaths registered, we identified all 31 cases of continuous deep sedation until death as reported by the GPs. GPs were interviewed face-to-face about patient characteristics, the decision-making process and characteristics of each case. Results: 28 interviews were conducted (response rate 28/31). 19 patients had cancer. 19 patients suffered persistently and unbearably. Pain was the main indication for continuous deep sedation (15 cases). In 6 cases, the patient was competent but was not involved in decision making. Relatives and care providers were involved in 23 cases and 18 cases, respectively. Benzodiazepines were used in 21 cases. During sedation, 11/28 of patients awoke, mostly due to insufficient medication. In 13 cases, the GP partially or explicitly intended to hasten the patients death. Conclusion: Continuous deep sedation until death, as practiced by Belgian GPs, is in most cases used for patients with unbearable suffering. Competent patients are not always involved in decision making while in most cases, the patients family is.

Similarities and differences between continuous sedation until death and euthanasia - professional caregivers' attitudes and experiences: A focus group study

Background: According to various guidelines about continuous sedation until death, this practice can and should be clearly distinguished from euthanasia, which is legalized in Belgium. Aim: To explore professional caregivers’ perceptions of the similarities and differences between continuous sedation until death and euthanasia. Design: Qualitative data were gathered through focus groups. Questions pertained to participants’ perceptions of continuous sedation. The focus groups were recorded and transcribed verbatim. Analyses were conducted by a multidisciplinary research team using constant comparison analyses. Setting/Participants: We did four focus groups at Ghent University Hospital: two with physicians (n = 4 and n = 4) and two with nurses (n = 4 and n = 9). The participants could participate if they were ever involved in the use of continuous sedation until death. Results: Although the differences and similarities between continuous sedation until death and euthanasia were not specifically addressed in the questions addressed in the focus groups, it emerged as an important theme in the participants’ accounts. Many caregivers elaborated on the differences between both practices, particularly with regard to patients’ preferences and requests, decision-making and physicians’ intentions. However, some stated that the distinction between the two sometimes becomes blurred, especially when the sedating medication is increased disproportionally or when sedation is used for patients with a longer life expectancy. Conclusions: The differences and similarities between continuous sedation until death and euthanasia is an issue for several Flemish professional caregivers in their care for unbearably suffering patients at the end of life. Although guidelines strictly distinguish both practices, this may not always be the case in Flemish clinical practice.

Continuous deep sedation until death in nursing home residents with dementia: a case series

To describe the characteristics of continuous deep sedation until death and the prior decision‐making process of nursing home residents dying with dementia and to evaluate this practice according to features reflecting sedation guideline recommendations.

The language of sedation in end-of-life care: The ethical reasoning of care providers in three countries.

The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care (‘care providers’), differences between countries in care providers’ ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is more likely to be organised like euthanasia, as the end ‘moment’ is reached, and family farewells are organised before the patient is made unconscious for ever. Medical and nursing practices are partly responses to factors outside the place of care, such as legislation and public sentiment. Dutch guidelines for sedation largely tally with the practices prevalent in the Netherlands and Belgium, in contrast with those produced by the more international European Association for Palliative Care whose authors describe an ethical framework closer to that reportedly used by UK care providers.

Physicians' experiences and perspectives regarding the use of continuous sedation until death for cancer patients in the context of psychological and existential suffering at the end of life

The use of continuous sedation until death for terminally ill cancer patients with unbearable and untreatable psychological and existential suffering remains controversial, and little in‐depth insight exists into the circumstances in which physicians resort to it.

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

Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patients 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.