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Prospective observational Italian study on palliative sedation in two hospice settings: differences in casemixes and clinical care

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Abstract

Purpose

Palliative sedation (PS) has been defined as the use of sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. It is sometimes necessary in end-of-life care when patients present refractory symptoms. We investigated PS for refractory symptoms in different hospice casemixes in order to (1) assess clinical decision-making, (2) monitor the practice of PS, and (3) examine the impact of PS on survival.

Methods

This observational longitudinal cohort study was conducted over a period of 9 months on 327 patients consecutively admitted to two 11-bed Italian hospices (A and B) with different casemixes in terms of median patient age (hospice A, 66 years vs. hospice B, 73 years; P = 0.005), mean duration of hospice stay (hospice A, 13.5 days vs. hospice B, 18.3 days; P = 0.005), and death rate (hospice A, 57.2% vs. hospice B, 89.9%; P < 0.0001). PS was monitored using the Richmond Agitation–Sedation Scale (RASS). Sedated patients constituted 22% of the total admissions and 31.9% of deceased patients, which did not prove to be significantly different in the two hospices after adjustment for casemix.

Results

Patient involvement in clinical decision-making about sedation was significantly higher in hospice B (59.3% vs. 24.4%; P = 0.007). Family involvement was 100% in both hospices. The maximum level of sedation (RASS, −5) was necessary in only 58.3% of sedated patients. Average duration of sedation was similar in the two hospices (32.2 h [range, 2.5–253.0]). Overall survival in sedated and nonsedated patients was superimposable, with a trend in favor of sedated patients.

Conclusions

PS represents a highly reproducible clinical intervention with its own indications, assessment methodologies, procedures, and results. It does not have a detrimental effect on survival.

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References

  1. Costantini M, Beccaro M, Merlo F, Study Group ISDOC (2005) The last three months of life of Italian cancer patients. Methods, sample characteristics and response rate of the Italian Survey of the Dying of Cancer (ISDOC). Palliat Med 19:628–638

    Article  PubMed  Google Scholar 

  2. Temel JS, Greer JA, Muzikansky A et al (2005) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742

    Article  Google Scholar 

  3. Cherny N, Catane R, Schrijvers D, Kloke M, Strasser F (2010) European Society for Medical Oncology (ESMO) program for the integration of Oncology and Palliative Care: a 5-year review of the Designated Centers’ incentive program. Ann Oncol 21:362–369

    Article  PubMed  CAS  Google Scholar 

  4. Van der Heide A, Deliens L, Faisst K et al (2003) End-of-life decision-making in six European countries: descriptive studies. Lancet 362:345–350

    Article  PubMed  Google Scholar 

  5. De Graeff A, Dean M (2007) Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med 10:67–85

    Article  PubMed  Google Scholar 

  6. Carr MF, Mohr GJ (2008) Palliative sedation as part of a continuum of palliative care. J Palliat Med 11:76–81

    Article  PubMed  Google Scholar 

  7. Maltoni M, Pittureri C, Scarpi E et al (2009) Palliative sedation therapy does not hasten death: results from a prospective multicenter study. Ann Oncol 20:1163–1169

    Article  PubMed  CAS  Google Scholar 

  8. Sykes N, Thorns A (2003) The use of opioids and sedation at the end of life. Lancet Oncol 4:312–318

    Article  PubMed  Google Scholar 

  9. Materstvedt LJ, Clark D, Ellershaw J et al (2003) Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med 17:97–101

    Article  PubMed  Google Scholar 

  10. Miccinesi G, Rietjens J, Deliens L et al (2006) Continuous deep sedation: physicians’ experiences in six European countries. J Pain Symptom Manag 31:122–129

    Article  Google Scholar 

  11. Cherny NI, Portenoy RK (1994) Sedation in the management of refractory symptoms: guidelines for evaluation and treatment. J Palliat Care 10:31–38

    PubMed  CAS  Google Scholar 

  12. Cherny NI, Radbruch L, Board of the European Association for Palliative Care (2009) European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 23:581–593

    Article  PubMed  Google Scholar 

  13. Kirk TW, Mahon MM, Palliative Sedation Task Force of the National Hospice and Palliative Care Organization Ethics Committee (2010) National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manag 39:914–923

    Article  Google Scholar 

  14. van Dooren S, van Veluw HT, van Zuylen L et al (2009) Exploration of concerns of relatives during continuous palliative sedation of their family members with cancer. J Pain Symptom Manag 38:452–459

    Article  Google Scholar 

  15. Morita T, Akechi T, Sugawara Y et al (2002) Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: a nationwide survey. J Clin Oncol 20:758–764

    Article  PubMed  Google Scholar 

  16. Schuman-Oliver Z, Brendel DH, Forstein M, Price BH (2008) The use of palliative sedation for existential distress: a psychiatric perspective. Harv Rev Psychiatr 16:339–351

    Article  Google Scholar 

  17. Kaplan EL, Meier P (1958) Non parametric estimation for incomplete observation. J Am Stat Assoc 53:457–481

    Article  Google Scholar 

  18. Lawless JS (1982) Statistical models and methods for life-time data. Wiley, New York

    Google Scholar 

  19. Ventafridda V, Ripamonti C, De Conno F, Tamburini M, Cassileth BR (1990) Symptom prevalence and control during cancer patients’ last days of life. J Palliat Care 6:7–11

    PubMed  CAS  Google Scholar 

  20. Porta Sales J (2001) Sedation and terminal care. Eur J Palliat Care 8:97–100

    Google Scholar 

  21. Peruselli C, Di Giulio P, Toscani F et al (1999) Home palliative care for terminal cancer patients: a survey on the final week of life. Palliat Med 13:233–241

    Article  PubMed  CAS  Google Scholar 

  22. Fainsinger RL, Waller A, Bercovici M et al (2000) A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med 14:257–265

    Article  PubMed  CAS  Google Scholar 

  23. Sessler CN, Gosnell MS, Grap J et al (2002) The Richmond Agitation–Sedation Scale. Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166:1338–1344

    Article  PubMed  Google Scholar 

  24. Bruera E, Sala R, Rico MA et al (2005) Effects of parenteral hydration in terminally ill cancer patients: a preliminary study. J Clin Oncol 23:2366–2371

    Article  PubMed  Google Scholar 

  25. Good P, Cavenagh J, Mather M, Ravenscroft P (2008) Medically assisted hydration for palliative care patients. Cochrane Database Syst Rev (2):CD006273

  26. Morita T, Tsunoda J, Inoue S, Chihara S (2001) Effects of high dose opioids and sedatives on survival in terminally ill cancer patients. J Pain Symptom Manag 21:282–289

    Article  CAS  Google Scholar 

  27. Morita T, Chinone Y, Ikenaga M et al (2005) Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan. J Pain Symptom Manag 30:320–328

    Article  Google Scholar 

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Acknowledgements

Funding was received from the Italian Ministry of Health as part of the Oncology Research Project “Ricerca Sanitaria Finalizzata ex art. 12 D.Lgs. 502/92, 2006. Programma Integrato Oncologia (area tematica 6)”. The funding source was not involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors thank Gráinne Tierney for editing the manuscript.

Disclosures

The authors declare no conflicts of interest.

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Authors and Affiliations

  1. Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (I.R.S.T.), Meldola, Italy

    Marco Maltoni & Dino Amadori

  2. Clinical and Descriptive Epidemiology Unit, Istituto per lo Studio e la Prevenzione Oncologica (ISPO), Florence, Italy

    Guido Miccinesi, Francesco Bulli & Eugenio Paci

  3. Convento delle Oblate Hospice, Azienda Sanitaria, Florence, Italy

    Piero Morino & Filippo Canzani

  4. Unit of Biostatistics and Clinical Trials, I.R.S.T., Meldola, Italy

    Emanuela Scarpi & Monia Dall’Agata

  5. Palliative Care Unit, Forlimpopoli Hospital, Forlimpopoli, Italy

    Francesca Martini

  6. Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute (ISPO), Via Oblate 2, Florence, 50141, Italy

    Guido Miccinesi

Authors
  1. Marco Maltoni
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  2. Guido Miccinesi
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  3. Piero Morino
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  4. Emanuela Scarpi
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  5. Francesco Bulli
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  6. Francesca Martini
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  7. Filippo Canzani
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  8. Monia Dall’Agata
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  9. Eugenio Paci
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  10. Dino Amadori
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Corresponding author

Correspondence to Guido Miccinesi.

Appendix

Appendix

Richmond Agitation–Sedation Scale (RASS)

RASS description

+4 Combative, violent, danger to staff

+3 Pulls or removes tube(s) or catheters; aggressive

+2 Frequent nonpurposeful movement, fights ventilator

+1 Anxious, apprehensive, but not aggressive

0 Alert and calm

−1 Awakens to voice (eye opening/contact) >10 s

−2 Light sedation, briefly awakens to voice (eye opening/contact) <10 s

−3 Moderate sedation, movement or eye opening; no eye contact

−4 Deep sedation, no response to voice, but movement or eye opening to physical stimulation

−5 Unarousable, no response to voice or physical stimulation

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Maltoni, M., Miccinesi, G., Morino, P. et al. Prospective observational Italian study on palliative sedation in two hospice settings: differences in casemixes and clinical care. Support Care Cancer 20, 2829–2836 (2012). https://doi.org/10.1007/s00520-012-1407-x

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  • DOI: https://doi.org/10.1007/s00520-012-1407-x

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