scholarly journals Palliative opioid use, palliative sedation and euthanasia: reaffirming the distinction

2019 ◽  
Vol 46 (1) ◽  
pp. 48-50 ◽  
Author(s):  
Guy Schofield ◽  
Idris Baker ◽  
Rachel Bullock ◽  
Hannah Clare ◽  
Paul Clark ◽  
...  
Keyword(s):  
Palliative Care ◽  
Real World ◽  
Symptom Control ◽  
Evidence Base ◽  
Routine Care ◽  
Palliative Sedation ◽  
Routine Practice ◽  
Opioid Use ◽  
Important Distinction ◽  
Opioid Prescribing

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation (CDPS) is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice.

Using medication in children’s palliative care

2021 ◽  
pp. 145-152
Author(s):  
Andy Gray ◽  
Jane Riddin ◽  
Richard Hain
Keyword(s):  
Palliative Care ◽  
Symptom Control ◽  
Evidence Base ◽  
Oral Route ◽  
Essential Medicines ◽  
Insufficient Evidence ◽  
Rights Of The Child ◽  
Child Friendly ◽  
The Individual ◽  
Alternative Routes

Using medication in children’s palliative care (CPC) is fraught with difficulties as a result of an insufficient evidence-base and a lack of child friendly formulations, however this cannot be a reason not to intervene and allow unnecessary suffering. A lack of access in some countries to even essential medicines such as opioids is an infringement of the rights of the child to pain relief and needs urgent redress. Often, the only reasonable option is to extrapolate from adult data and to proceed rationally on the basis of what the prescriber knows about the available drug, the individual child, and the likely effects of their disease. Alternative routes for administration of medicines in children who are no longer able to use the oral route, such as the trans- and sub-cutaneous and buccal route mean symptom control can be provided at home and until end of life.

A response to critics: weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

2019 ◽  
Vol 46 (1) ◽  
pp. 59-62 ◽  
Author(s):  
Thomas D Riisfeldt
Keyword(s):  
Palliative Care ◽  
Human Life ◽  
Double Effect ◽  
Palliative Sedation ◽  
Care Provision ◽  
Doctrine Of Double Effect ◽  
Opioid Use ◽  
Category Mistake ◽  
Original Argument ◽  
Cherry Picking

My essay ‘Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation’ has recently generated some critique which I will attempt to address in this response. Regarding the empirical question of whether palliative opioid and sedative use shorten survival time, Schofield et al raise the three concerns that my literature review contains a cherry-picking bias through focusing solely on the palliative care population, that continuous deep palliative sedation falls beyond the scope of routine palliative care, and that my research may contribute to opiophobia and be harmful to palliative care provision globally. Materstvedt argues that euthanasia ‘ends’ rather than ‘relieves’ suffering and is not a treatment, and that the arguments in my essay are therefore predicated on a ‘category mistake’ and are a non-starter. Symons and Giebel both raise the concern that my Kantian and Millian interpretation of the Doctrine of Double Effect is anachronistic, and that when interpreted from the contemporaneous perspective of Aquinas it is a sound ethical principle. Giebel also argues that palliative opioid and sedative use do meet the Doctrine of Double Effect’s four criteria on this Thomistic account, and that it does not contradict the Doctrine of the Sanctity of Human Life. In this response I will explore and defend against most of these claims, in doing so clarifying my original argument that the empirical and ethical differences between palliative opioid/sedative use and euthanasia may not be as significant as often believed, thereby advancing the case for euthanasia.

scholarly journals Micro-Meso-Macro Practice Tensions in Using Patient-Reported Outcome and Experience Measures in Hospital Palliative Care

2018 ◽  
Vol 29 (4) ◽  
pp. 510-521 ◽  
Author(s):  
Marian Krawczyk ◽  
Richard Sawatzky ◽  
Kara Schick-Makaroff ◽  
Kelli Stajduhar ◽  
Joakim Öhlen ◽  
...  
Keyword(s):  
Palliative Care ◽  
Analytical Framework ◽  
Routine Care ◽  
Patient Reported Outcome ◽  
Scope Of Practice ◽  
Routine Practice ◽  
Macro Practice ◽  
Patient Reported ◽  
Critical Consideration

This article applies a micro-meso-macro analytical framework to understand clinicians’ experiences and perspectives of using patient-reported outcome and experience measures (PROMs and PREMs) in routine hospital-based palliative care. We structure our discussion through qualitative analysis of a design and implementation project for using an electronic tablet-based tool among hospital-based palliative clinicians to assess patients’ and their family caregivers’ quality of life concerns and experiences of care. Our analysis identified three categories of practice tensions shaping clinicians’ use of PROMs and PREMs in routine care: tensions surrounding implementation, tensions in standardization and quantification, and tensions that arose from scope of practice concerns. Our findings highlight that clinicians necessarily work within the confluence of multiple system priorities, that navigating these priorities can result in irreducible practice tensions, and that awareness of these tensions is a critical consideration when integrating PROMs and PREMs into routine practice.

Role of Palliative Care in Adolescent and Young Adult Oncology

2010 ◽  
Vol 28 (32) ◽  
pp. 4819-4824 ◽  
Author(s):  
Simon Wein ◽  
Shlomit Pery ◽  
Alona Zer
Keyword(s):  
Palliative Care ◽  
Symptom Control ◽  
National Level ◽  
Evidence Base ◽  
Young Person ◽  
Good Evidence ◽  
Adolescent And Young Adult ◽  
Professional Organizations ◽  
Key Skills ◽  
Developmental Phases

Adolescents and young adults (AYAs) with cancer are a heterogeneous group. Nevertheless, there are sufficient unifying characteristics to form a distinct clinical entity. Management of this special group requires a broad-based interdisciplinary clinical team, which should include palliative care (PC), psychology, social work, oncology, and nursing representatives. The function of PC is to provide impeccable pain and other symptom control and to coordinate care as the disease progresses. Features unique to AYAs with cancer include the psychosocial developmental phases, a young person facing death, grief, and bereavement. Pharmacologic and medical interventions by PC in AYAs are broadly similar to adults. Developing trust and being flexible are key skills that PC must use with AYAs. There is a paucity of high-quality controlled studies in the PC literature in general and AYA-PC in particular. Therefore, the methodology of this article is largely based on the narrative and clinical experience. The experience is based on clinicians' work with AYAs with cancer in Israel and Australia. Clinical lessons will be drawn by comparing and contrasting the cultures. Nevertheless, most PC clinical interventions, both pharmacologic and psychosocial, are derived from literature where there is a good evidence base. Future development of PC within AYAs should be coordinated at a national level via appropriate palliative and oncology professional organizations.

scholarly journals Hypnosis in a specialist palliative care setting – enhancing personalized care for difficult symptoms and situations

2020 ◽  
Vol 14 ◽  
pp. 263235242095343
Author(s):  
Sara Booth
Keyword(s):  
Palliative Care ◽  
Care Setting ◽  
Symptom Control ◽  
Evidence Base ◽  
Self Management ◽  
Specialist Palliative Care ◽  
Personalized Care ◽  
Improve Symptom ◽  
Palliative Care Setting

This is a personal account of using hypnosis as an adjunct to specialist palliative care (SPC) treatment approaches. After a brief systematic review of the literature, one clinician’s experience is outlined illustrated by short, anonymized case histories. It argues that the approach is underused in SPC. The barriers currently restricting its routine adoption in SPC are discussed including (1) a lack of SPC clinical trials, (2) a misunderstanding of hypnosis leading to stigma, and (3) its absence from clinicians’ training pathways. While the evidence base for the effectiveness of hypnosis in ‘supportive care’, for example, managing chemotherapy-induced vomiting, is appreciable, there is a gap in SPC. There is little data to guide the use of hypnosis in the intractable symptoms of the dying, for example, breathlessness or the distress associated with missed or late diagnosis. There are many people now ‘living with and beyond cancer’ with chronic symptomatic illness, ‘treatable but not curable’. Patients often live with symptoms over a long period, which are only partially responsive to pharmacological and other therapies. Hypnosis may help improve symptom control and quality of life. SPC trials are needed so that this useful tool for self-management of difficult symptoms can be more widely adopted.

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

2018 ◽  
Vol 45 (2) ◽  
pp. 125-130 ◽  
Author(s):  
Thomas David Riisfeldt
Keyword(s):  
Palliative Care ◽  
Survival Time ◽  
Empirical Evidence ◽  
Double Effect ◽  
Palliative Sedation ◽  
Ethical Principle ◽  
Doctrine Of Double Effect ◽  
Opioid Use ◽  
Care Services ◽  
Palliative Care Services

Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.

Characterisation of palliative sedation use in inpatients at a medium-stay palliative care unit

2020 ◽  
Vol 26 (7) ◽  
pp. 341-345
Author(s):  
Efrén Murillo-Zamora ◽  
Nallely A García-López ◽  
Ana de Santiago-Ruiz ◽  
Alcira Emperatriz Chávez-Lira ◽  
Oliver Mendoza-Cano ◽  
...  
Keyword(s):  
Palliative Care ◽  
Heart Disease ◽  
Liver Dysfunction ◽  
Symptom Control ◽  
Cross Sectional Study ◽  
Palliative Sedation ◽  
Palliative Care Unit ◽  
Cross Sectional ◽  
Accepted Practice ◽  
Sedative Drugs

Background Palliative sedation has been used to refer to the practice of providing symptom control through the administration of sedative drugs. The objective of this article was to characterise palliative sedation use in inpatients at a medium-stay palliative care unit. Material and methods A cross-sectional study was conducted on 125 randomly selected patients (aged 15 or older) who had died in 2014. The Palliative Performance Scale was used to evaluate the functional status. Results Palliative sedation was documented in 34.4% of the patients and midazolam was the most commonly used sedative agent (86.0%). More than half (53.5%) of those who recieved sedation presented with delirium. Liver dysfunction was more frequent in the sedated patients (p=0.033) and patients with heart disease were less likely (p=0.026) to be sedated. Conclusion Palliative sedation is an ethically accepted practice. It was commonly midazolam-induced, and differences were documented, among sedated and non-sedated patients, in terms of liver dysfunction and heart disease.

Palliative Sedation at Home

2009 ◽  
Vol 25 (1) ◽  
pp. 5-11 ◽  
Author(s):  
Ora S. Rosengarten ◽  
Yonat Lamed ◽  
Timna Zisling ◽  
Ayelet Feigin ◽  
Jeremy M. Jacobs
Keyword(s):  
Palliative Care ◽  
Median Time ◽  
Treatment Option ◽  
Symptom Control ◽  
Palliative Sedation ◽  
Intractable Pain ◽  
Existential Suffering ◽  
Dying Patients ◽  
Care At Home ◽  
At Home

A large number of dying patients receive palliative care at home, and although palliative sedation (PS) may be indicated, literature describing PS at home is scarce. This study is a retrospective description of PS delivered to terminal patients at home from December 2000 to March 2006. A total of 36 patients (with a median age of 65) received home PS. Cancer was the diagnosis for 35 patients, and most patients suffered more than one symptom — most commonly, intractable pain, followed by agitation and existential suffering. Drugs used included midazolam, morphine, haloperidol, fentanyl TTS, and promethazine. Median duration of sedation was three days; median time to symptom control was 24 hours. Good symptom control was achieved in 28 out of 36 patients, and 34 of the patients died at home. In conclusion, PS was a feasible and successful treatment option, improving the care of terminal patients whose preference is to die at home.

scholarly journals Treating to target in psoriatic arthritis: assessing real-world outcomes and optimising therapeutic strategy for adults with psoriatic arthritis—study protocol for the MONITOR-PsA study, a trials within cohorts study design

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Ines Rombach ◽  
William Tillett ◽  
Deepak Jadon ◽  
Laura Tucker ◽  
Marion Watson ◽  
...  
Keyword(s):  
Psoriatic Arthritis ◽  
Real World ◽  
Clinical Effectiveness ◽  
Evidence Base ◽  
Routine Care ◽  
Treat To Target ◽  
Disease Modifying Therapy ◽  
Trials Within Cohorts ◽  
Remission Criteria ◽  
Monitoring Treatment

Abstract Background The Tight Control of psoriatic arthritis (TICOPA) trial confirmed improved clinical outcomes with a treat to target (T2T) strategy in psoriatic arthritis (PsA). This consisted of 4-weekly review and escalation of ‘step up’ therapy (single disease modifying therapy (DMARD), combination DMARDs and then biologics) based on remission criteria. Based on this, a T2T approach is supported by European PsA treatment recommendations. However, it is not commonly implemented in routine care primarily due to feasibility and cost concerns. In the TICOPA trial, the same treatment regime was used for all participants regardless of their disease profile. Despite the recognition of PsA as a highly heterogeneous condition, no studies have tailored which drugs are used depending on disease severity. The cohort will establish real world outcomes for the T2T approach in PsA and also form the basis of a trials within cohorts (TWiCs) design to test alternative therapeutic approaches within embedded clinical trials providing an evidence base for treatment strategy in PsA. Methods The Multicentre Observational Initiative in Treat to target Outcomes in Psoriatic Arthritis (MONITOR-PsA) cohort will apply a T2T approach within routine care. It will recruit newly diagnosed adult patients with PsA starting systemic therapies. The cohort is observational allowing routine therapeutic care within NHS clinics but a T2T approach will be supported when monitoring treatment within the cohort. Eligible participants will be adults (≥18 years) with active PsA with ≥ 1 tender or swollen joints or enthesis who have not previously had treatment with DMARDs for articular disease. Discussion This study is the first TWiC designed to support a fully powered randomised drug trial. The results from the observational cohort will be compared with those observed in the TICOPA trial investigating the clinical effectiveness and health care costs of the pragmatic T2T approach. Nested trials will provide definitive RCT evidence establishing the optimal management of PsA within the T2T approach. The TWiCs design allows robust generalizability to routine healthcare, avoids disappointment bias, aids recruitment and in future will allow assessment of longer-term outcomes. Trial registration ClinicalTrials.gov NCT03531073. Retrospectively registered on 21 May 2018.

Symptom prevalence of cancer patients dying with and without palliative sedation at a specialized unit for palliative care in a cancer center

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 8576-8576
Author(s):  
L. Van Zuylen ◽  
L. Van der Wijk ◽  
H. Van Veluw ◽  
A. Van der Heide ◽  
C. C. Van der Rijt
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Symptom Control ◽  
Patient Characteristics ◽  
Palliative Sedation ◽  
Cancer Center ◽  
Symptom Profile ◽  
Symptom Prevalence ◽  
Specialized Unit ◽  
Prevalence Of Cancer

8576 Background: Palliative sedation (PS) may be needed in dying cancer patients to achieve acceptable symptom control. Little is known about the differences between sedated and non-sedated patients. To determine characteristics of sedated and non-sedated patients, we performed a retrospective study in patients who died during admission to the palliative care unit (PCU) of the cancer center. Methods: From October 2001 until October 2005, 157 out of 753 admitted patients died at the PCU. The medical and nursing records were studied with respect to patient characteristics and the symptom profile at admission and during the last 72 hrs of life. Results: Of all deceased patients, 68 (43%) were sedated prior to death. The median duration of the sedation was 19 hrs (range 0.7–125). No differences between sedated and non-sedated patients were found in age (median 58 years, range 25–89) and time between admission and death (7 days, 1–38). The primary tumor sites were mostly lung (22.1%), GI tract (20.6%), and breast (16.2%) in the sedated patients, and breast (24.7%), lung (13.5%) and urogenital tract (11.2%) in the non-sedated patients. The symptoms at admission were mainly pain (82%), constipation (43%) and dyspnea (31%) and did not differ between both groups. Prior to the start of PS, sedated patients more often had delirium and dyspnea as compared to non-sedated patients at similar times before death. Conclusions: PS was needed to control symptoms for somewhat less than half of the patients dying at the PCU. Pain was a main reason for admission in both groups, but dyspnea and delirium were more common in sedated patients during admission. [Table: see text] No significant financial relationships to disclose.

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