Continuous Deep Sedation Until Death Is Not an Alternative to Assisted Suicide in Palliative Care Units in the French-Speaking Part of Switzerland: A Multicentre Qualitative Study Based on Interviews With Physicians.

Abstract Background: According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to a request for death. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to active assisted dying in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated if they might be correlated. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as an alternative to assisted suicide in the French-speaking part of Switzerland.Methods: We performed an exploratory multicentre qualitative study based on interviews with physicians working in palliative care institutions in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ criteria.Results: We included 10 interviews conducted in four palliative care institutions. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) is not considered an alternative to assisted suicide. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, is sometimes introduced in response to a request for assisted suicide. This is due to the impossibility of carrying out an assisted suicide at home (e.g., home transfer is impossible or the patient’s wish not to traumatize the family).Conclusion: These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.

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A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland

BMC Palliative Care ◽

10.1186/s12904-021-00761-y ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Martyna Tomczyk ◽

Nathalie Dieudonné-Rahm ◽

Ralf J. Jox

Keyword(s):

Palliative Care ◽

Qualitative Study ◽

Assisted Suicide ◽

Deep Sedation ◽

Palliative Sedation ◽

Continuous Deep Sedation ◽

French Speaking ◽

Potential Alternative ◽

Palliative Care Units ◽

Negative Impacts

Abstract Background According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. Methods We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. Results We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). Conclusion These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.

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Reflections on palliative sedation

Palliative Care Research and Treatment ◽

10.1177/1178224218823511 ◽

2019 ◽

Vol 12 ◽

pp. 117822421882351 ◽

Cited By ~ 9

Author(s):

Robert Twycross

Keyword(s):

Palliative Care ◽

Deep Sedation ◽

Palliative Sedation ◽

Palliative Care Team ◽

Specific Symptom ◽

Care Services ◽

Continuous Deep Sedation ◽

Continuous Sedation ◽

Palliative Care Services ◽

Intolerable Suffering

‘Palliation sedation’ is a widely used term to describe the intentional administration of sedatives to reduce a dying person’s consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either ‘continuous sedation until death’ or ‘continuous deep sedation’. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person’s ‘biographical life’ (the ability to interact meaningfully with other people) and shortens ‘biological life’. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become ‘normalized’ in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.

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Practices and Attitudes of Japanese Oncologists and Palliative Care Physicians Concerning Terminal Sedation: A Nationwide Survey

Journal of Clinical Oncology ◽

10.1200/jco.2002.20.3.758 ◽

2002 ◽

Vol 20 (3) ◽

pp. 758-764 ◽

Cited By ~ 36

Author(s):

Tatsuya Morita ◽

Tatsuo Akechi ◽

Yuriko Sugawara ◽

Satoshi Chihara ◽

Yosuke Uchitomi

Keyword(s):

Palliative Care ◽

Cancer Patients ◽

Psychiatric Treatment ◽

Deep Sedation ◽

Terminally Ill ◽

Palliative Sedation ◽

Professional Burnout ◽

Palliative Sedation Therapy ◽

Continuous Deep Sedation ◽

Psychologic Distress

PURPOSE: To clarify the frequency of practice of sedation therapy for terminally ill cancer patients and to identify physicians’ attitudes toward sedation. METHODS: Questionnaires were mailed to 1,436 Japanese oncologists and palliative care physicians with a request to report their practice of and attitudes toward palliative sedation therapy. RESULTS: A total of 697 physicians returned questionnaires (response rate, 49.6%). Use of mild, intermittent-deep, or continuous-deep sedation for physical and psychologic distress was reported by 89% and 64%, 70% and 46%, and 66% and 38%, respectively. In vignettes in which physicians were asked whether they would use sedation for a patient with refractory dyspnea or with existential distress, 14% and 15%, respectively, chose continuous-deep sedation as a strong possibility. Those physicians less confident with psychologic care and with higher levels of professional burnout were more likely to choose continuous-deep sedation. In vignettes in which they were asked whether they use sedation for a patient with depression or delirium, 39% and 31%, respectively, considered psychiatric treatment to be a strong possibility, and 42% and 50% regarded continuous-deep sedation as a potential treatment option. Physicians less involved in caring for the terminally ill and less specialized in palliative medicine were significantly less likely to choose psychiatric treatment. CONCLUSION: Sedation is frequently used for severe physical and psychologic distress of cancer patients. Physicians’ clinical experiences with the terminally ill and their levels of professional burnout influence the decisions. Training and education for physicians in regard to end-of-life care and valid clinical guidelines for palliative sedation therapy are necessary.

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Requests for euthanasia and assisted suicide: A qualitative study of the wordings of requests from patients at the end of life hospitalised in palliative care units.

10.21203/rs.2.18924/v1 ◽

2019 ◽

Author(s):

Florence Mathieu-Nicot ◽

Aline Chassagne ◽

Daniele Leboul ◽

Anne Bousquet ◽

Aurélie Godard-Marceau ◽

...

Keyword(s):

Palliative Care ◽

Qualitative Study ◽

End Of Life ◽

Assisted Suicide ◽

Third Party ◽

Physician Assisted Suicide ◽

Structured Interviews ◽

Initial Request ◽

Registration Number ◽

Palliative Care Units

Abstract Background Whilst euthanasia and assisted suicide are forbidden by French Law, patients at the end of life, hospitalized in Palliative Care Units, sometimes express the Wish to Hasten their Death. Few Studies have analyzed the formulation of these patient requests in interviews and the associated death-related representations. The DESA study analyzed the expression of patients’ requests, focusing on the terms and how patients worded their wishes. The aim is to identify from the “raw wording” of the patients’ requests, the means of expressing them in all its singularity and evolution. Methods This is a qualitative study that took place in 11 French Palliative care Units during on year and included adult patients who had made an explicit request (euthanasia or physician assisted suicide) to a health care provider. Semi-structured interviews were conducted within 48 hours of the initial request (D0), then a week later (D7). Results At DO, the initial request is a request for euthanasia and it calls a third person urgently. This request is related to physical and psychological suffering, trauma and representations of death. At D7, we observe a semantic change; the request is less explicit and requires less intervention by a third party. The quest remains that of a death without suffering. Conclusions These patients express themselves easily on their request and listening is necessary to be able to hear the meaning of the words but also their functions. It is their nuance, variety and evolution that help to understand what the requirements mean. Trial registration number : ClinicalTrials.gov Identifier: NCT02845817

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Japanese physicians’ experiences of terminally ill patients voluntarily stopping eating and drinking: a national survey

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2017-001426 ◽

2017 ◽

Vol 9 (2) ◽

pp. 143-145 ◽

Cited By ~ 8

Author(s):

Takuya Shinjo ◽

Tatsuya Morita ◽

Daisuke Kiuchi ◽

Masayuki Ikenaga ◽

Hirofumi Abo ◽

...

Keyword(s):

Palliative Care ◽

National Survey ◽

Clinical Setting ◽

Deep Sedation ◽

Terminally Ill ◽

Treatment Decision ◽

Mail Questionnaire ◽

Terminally Ill Patients ◽

Continuous Deep Sedation

ObjectivesVoluntarily stopping eating and drinking (VSED) could be regarded as a patients’ own non-treatment decision that hastens death, which involves patients voluntarily forgoing food and liquid until death. The aims of this study were to investigate the experience of home hospice physicians and palliative care specialists who care for patients during VSED in Japan, and their opinions on continuous deep sedation (CDS) as a means to relieve patient symptoms during VSED.Methods219 home hospice physicians and 695 palliative care specialists across Japan were surveyed by mail questionnaire in 2016.ResultsA total of 571 (62%) responses were analysed. A total of 185 (32%) had experience of patients who selected VSED. In response to questions about CDS to provide relief to patients during VSED, the number of physicians who replied that CDS was acceptable was 88 (15%).ConclusionsIn Japan, 32% of physicians surveyed replied that they had experience of caring for patients during VSED in a clinical setting and 15% considered CDS acceptable.

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