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Existential suffering is among the main symptoms refractory to treatment in people at the end of life. There is evidence in the literature on the use of palliative sedation, the controlled administration of sedative medication with the purpose of inducing a state of reduced consciousness or unconsciousness to relieve unbearable suffering experienced by people with terminal illnesses, to control existential suffering. This article presents the protocol for an integrative review which aims to analyze the evidence available in the literature on the use of palliative sedation to manage existential suffering in people with serious end-of-life illnesses. This is an integrative review protocol based on the steps described by Whittemore and Knalf, and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). A comprehensive search strategy including carefully selected terms corresponding to the domains of interest (palliative sedation and existential suffering) will be used to search for the relevant literature in the PubMed, Scopus, Web of Science, CINAHL, Cochrane Library, and EMBASE databases. The Endnote and Rayyan softwares will be used for data management. This integrative review aims to identify existing gaps and contribute to the presentation of information that may contribute to settling the controversy regarding the use of palliative sedation to manage refractory existential suffering at the end of life. Open Science Framework (). [ABSTRACT FROM AUTHOR]

Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients. [ABSTRACT FROM AUTHOR]

End of life (EoL) and refractory symptom management is a growing clinical topic and there is minimal literature to support effective treatment strategies, especially in individuals with a substance use disorder or opioids and/or benzodiazepine tolerance. We report the successful use of phenobarbital for proportionate EoL sedation in a 57-year-old man with opioid use disorder (heroin) and metastatic urothelial carcinoma presenting to an acute care hospital with intractable back pain related to bone metastases. During his hospitalization, his daily opioid requirement exceeded 1 gram of morphine equivalent daily dose (MEDD) with suboptimal pain control. The patient's clinical course was complicated by active heroin withdrawal, psychosocial suffering, and disease progression. Despite use of high-dose opioids and benzodiazepines, pain and anxiety were poorly controlled. After an acute medical decompensation, a goals of care discussion was held with his family and a determination with informed consent was made to change patient status to do not attempt resuscitation and proportionate sedation with phenobarbital was initiated to target refractory pain and agitation. Phenobarbital was continued for approximately 15 hours before patient peacefully died. Findings from this case report demonstrate the successful use of phenobarbital in opioid use disorder and benzodiazepine tolerance with intractable pain. [ABSTRACT FROM AUTHOR]

Continuous deep sedation (CDS) is used to alleviate unbearable and otherwise refractory symptoms in patients dying of cancer. No data are available concerning CDS in children from Japan to date. This study primarily aimed to describe experience in CDS in child cancer patients at Kyoto University Hospital. The secondary aims were to identify the characteristics of patients who received CDS, and to assess ability in daily living at the end of life. A retrospective chart review was performed for child cancer patients who died at the institute between 2008 and 2017. The data of 35 patients were analyzed. Nine (26%) patients had received CDS. Indications for CDS were dyspnea (56%), agitation (22%), seizures (22%), and pain (11%). Midazolam was used in all nine cases. In eight (89%) patients, opioids were also prescribed. In seven (78%) patients, CDS was performed for < 48 hours. In all nine cases, consent was obtained from the parent(s) but not from the children. CDS was more likely in patients with solid tumors (p = 0.018) and those who had received no respite sedation (p = 0.002). Patients without central nervous system symptoms tended to maintain their capacity for oral intake and verbal communication until a few days prior to death. This is the first report on CDS in child cancer patients from Japan. In the CDS literature, cross-study differences are evident for incidence, target symptoms, duration, and the decision-making process. Further international discussion is warranted concerning indications for CDS and the decision-making process. [ABSTRACT FROM AUTHOR]

Objective: This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes. Methods: We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD. Results: 50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only. Conclusion: ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations. [ABSTRACT FROM AUTHOR]

Delirium is a common problem in terminally ill patients that is associated with significant distress and, hence, considered a palliative care emergency. The three subtypes of delirium are hyperactive, hypoactive, and mixed, depending on the level of psychomotor activity and arousal disturbance. When agitated delirium becomes refractory in the setting of imminent dying, the agitation may be so severe that palliative sedation (PS) is required. Palliative sedation involves the administration of sedative medications with the purpose of reducing level of consciousness for patients with refractory suffering in the setting of a terminal illness. Propofol is a sedative that has a short duration of action and a very rapid onset. These characteristics make it relatively easy to titrate. Reported doses range from 50 to 70 mg per hour. The authors present a case of antipsychotic-resistant agitated delirium treated with a propofol intravenous infusion. [ABSTRACT FROM PUBLISHER]

Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner. [ABSTRACT FROM AUTHOR]

Palliative sedation (PS) is used increasingly commonly for symptom management in terminally ill patients in the Western world. The main controversies involving PS are whether it is the same as euthanasia, whether the practice supports patient autonomy, whether sufficient safeguards are or could be in place to prevent its abuse and what its spread may mean for the future of palliative care. While other reviews consider them separately, here the legal, scientific, ethical, and pragmatic challenges to the practice are examined together to provide a broad context in which to assess the current state of the practice. [ABSTRACT FROM AUTHOR]

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the resources available to successfully manage them is effective palliative care. However, this could hasten death in this vulnerable population and hence, while ethically and medically justifiable, is not without social risk. [ABSTRACT FROM PUBLISHER]

Intractable pain and other intolerable symptoms or the patients' wish to exercise self-determination can mandate palliative sedation. Yet, three bioethical principles must be balanced in comparable situations: one and two being beneficence (to do the best for our patient) and non-maleficence (do no harm) versus patient autonomy (the right for self-determination). Theoretically, palliative sedation incurs the potential risk of accelerating death, particularly in cases in which the disease is not advanced, because the consequences of sedation (perhaps no calorie or fluid uptake) would be likely to cause death (refusal to eat or drink sufficiently). If, however, the disease is far advanced (and the prognosticated life-span short) and the patient unwilling to eat and drink anyway, then initiated sedation might not be associated with accelerated death (and thus do harm to the patient, from an external viewpoint). Therefore, palliative sedation continues to be an area of discussion and a challenge as to when and how to implement it. Here, we introduce the case of a patient with advanced gastric cancer who asked for palliative sedation. We briefly describe his and the family's thoughts and follow the course of the disease until his death. With this report, we re-emphasize that, with precise sedation by continuous infusion of midazolam, it is possible to let the patient wake up for voiding and defecation and communicate with family members. By such individual approaches, it is possible to let the natural course of disease continue. Our patient had at no point in time asked for physician-assisted suicide. [ABSTRACT FROM AUTHOR]

At the end of life, all patients have the right to the adequate relief of physical symptoms. Consequently, there is need to ensure that appropriate infrastructural measures are addressed to enhance the likelihood that this right will be fulfilled. In order to achieve this, it is critical that symptoms at the end of life be assessed and, when relief is needed, that the adequacy of symptom relief be determined by the patient. Inadequately received symptoms in dying patients must be relieved to the patient's satisfaction and symptoms that are difficult to control must be evaluated by clinicians expert in symptom control at the end of life. When a symptom is refractory to normal palliative approaches, and only sedation can provide the needed relief, this should be available to patients with appropriate infrastructural guidelines to prevent the inappropriate application of this approach. [ABSTRACT FROM AUTHOR]

The complexities that converge around palliative sedation invite clinicians to work together to differentiate the issues and come to recommendations and decisions that are humane, ethical, legal, and clinically sound. Whether a crisis or long-term situation exists, the work is essentially the same. It must include critical thinking, clinical expertise, multidimensional assessment, and an array of interventions to assist patients and families in situations where symptoms and suffering are sufficiently intense to warrant exploration of sedation. The many issues inherent in the discussion of sedation at end of life require not that we have the answers but rather that we work with our colleagues to raise relevant questions and integrate both expertise and compassion into end-of-life decisions and care. [ABSTRACT FROM AUTHOR]

Despite progress in the treatment of pediatric cancer, approximately 25% of these children will die of the disease. The last period of life is characterized by profound physical and psychological suffering, both of the children and their loved ones. Adequate alleviation of this suffering becomes the priority in the management of these patients. The authors retrospectively evaluated the indications, incidence, and characteristics of palliative sedation (PS) in 19 children with brain tumors (BT) and 18 with sarcomas (S) at the end of life. Twelve of the 18 S patients received PS, as did 13 of the 19 BT patients. Indications for initiation of PS for those with BT were seizures and/or pain, for those with S were pain and/or respiratory insufficiency. It was concluded that PS may be the only efficacious and safe treatment for the alleviation of suffering in these children at the end of life, despite differing indications. [ABSTRACT FROM AUTHOR]

Sedation in end-of-life care is an accepted, but nonetheless controversial, means of providing relief from otherwise refractory and intolerable symptoms and distress. For purposes of this article, the terms 'palliative sedation' and "patient-controlled palliative sedation' (PCS) will be used to describe clinician-controlled or patient-controlled drug delivery. Ideally, therapy should improve symptoms without unfavorably affecting the patient's level of perception or capacity to communicate with friends and family members. Benzodiazepines, opioids, and certain neuroleptics have been used for palliative sedation with variable success and satisfaction rates. Propofol is a sedative-anesthetic with unique pharmacological properties which may prove highly desirable for use in selected terminally ill patients. There are few case reports and studies about using propofol as a continuous infusion for palliative sedation. Propofol-PCS has been used for sedation in certain surgical procedures in both young and elderly patients: however, its use in terminally ill patients has not been described. The authors postulate that propofol PCS may offer potential benefits for use in various situations at certain stages during terminal sedation. [ABSTRACT FROM AUTHOR]

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online (). The January 2015 issue (first DVD for 2015) contains 6277 complete reviews, 2355 protocols for reviews in production, and 34,000 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 832,000 randomized controlled trials, and 15,700 cited papers in the Cochrane Methodology Register. The Health Technology Assessment database contains some 14,000 citations. One hundred and ten new reviews have been published in the previous 3 months, of which six have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 5.939. Readers are encouraged to access the full report for any articles of interest, as only a brief commentary is provided. [ABSTRACT FROM AUTHOR]

In this observational and retrospective study, the authors aimed to evaluate how the practice of palliative terminal sedation therapy (PST) in a hospice setting has changed in a given period of clinical activity and which psychosocial factors have influenced it. We considered the prevalence of palliative/terminal sedation therapy (PST) and the prevalence of some factors associated with the decision-making process in PST (awareness of death, impairment of cognitive function, discussion of sedation with physicians, etc.). Despite a downward trend in patients without awareness of death, the interlocutor of the decision-making process is always the caregiver (44 vs. 28% for the patient). Furthermore, the probability that conscious sedation preceded deep sedation was significantly reduced when the principal interlocutor in the decision-making process was the caregiver. The weight of the decision-making of the patient seems to be relative to an awareness of the death process and the families’ responsibility is a relevant aspect in advanced care planning. [ABSTRACT FROM AUTHOR]