Background: When the suffering of a terminally ill patient is intolerable and refractory, sedatives are sometimes used for symptom relief. Objective: To describe the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Design: Consensus methods using the Delphi technique were used. Results: The main principles of the guidelines that were newly defined or developed are as follows: (1) palliative sedation was defined as \"administration of sedatives for the purpose of alleviating refractory suffering\" (excluding the aim of reducing patient consciousness); (2) palliative sedation was classified according to the method of administration of sedatives: respite sedation versus continuous sedation (including (continuous) proportional sedation and continuous deep sedation); (3) a description of state-of-the-art recommended treatments for difficult symptoms such as delirium, dyspnea, and pain before the symptom was determined as refractory was included; (4) the principle of proportionality was newly defined from an ethical point of view; and (5) families\' consent was regarded as being desirable (mandatory in the previous version). Conclusions: We described the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Further consensus building is necessary.

BACKGROUND: The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made.
METHODS: The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements.
RESULTS: This article provides a summary of the recommendations with rationales for each, as well as a short summary.
CONCLUSIONS: These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.

UNASSIGNED: Though palliative sedation has been recognized as an acceptable practice in Canada for many years now, there is a lack of clinical research and guidelines pertaining to its use as a treatment of existential refractory symptoms in the terminally ill.
UNASSIGNED: This scoping review aimed to survey the literature surrounding palliative sedation and existential suffering and to inform research, policy, and practice.
UNASSIGNED: To address the main research question: Is palliative sedation an acceptable intervention to treat existential refractory symptoms in adults aged 65 and older? a scoping review following Arksey and O\'Malley\'s framework was performed, spanning electronic databases of the peer reviewed and grey literature. Articles were screened for inclusion, and a thematic content analysis allowed for a summary of key findings.
UNASSIGNED: Out of 427 search results, 71 full text articles were obtained, 20 of which were included. Out of these articles, four themes were identified as key findings. These included: (1) Ethical considerations; (2) The role of the health care provider; looking specifically at the impact on nurses; (3) The need for multidisciplinary care teams; and (4) Existential suffering\'s connection to religiosity and spirituality.
UNASSIGNED: Palliative sedation to treat existential refractory symptoms was labelled a controversial practice. A shortage of evidence-based resources limits the current literature\'s ability to inform policy and clinical practice. There is a need for both qualitative and quantitative multi-center research so health care professionals and regional-level institutions have firm roots to establish proper policy and practice.

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BACKGROUND: The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD.
METHODS: Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy.
RESULTS: All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD.
CONCLUSIONS: This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.

OBJECTIVE: To present and discuss the views of researchers at an academic palliative care research centre on research encounters with terminally ill patients in the home setting and to generate a list of recommendations for qualitative researchers working in palliative and end-of-life care.
METHODS: Eight researchers took part in a consensus meeting to discuss their experiences of undertaking qualitative interviews. The researchers were of varying backgrounds and all reported having experience in interviewing terminally ill patients, and all but one had experience of interviewing patients in their home environment.
RESULTS: The main areas discussed by researchers included: whether participation in end-of-life research unintentionally becomes a therapeutic experience or an ethical concern; power relationships between terminally ill patients and researchers; researcher reflexivity and reciprocity; researchers\' training needs. Qualitative methods can complement the home environment; however, it can raise ethical and practical challenges, which can be more acute in the case of research undertaken with palliative and patients at the end-of-life.
CONCLUSIONS: The ethical and practical challenges researchers face in this context has the potential to place both participant and researcher at risk for their physical and psychological well-being. We present a set of recommendations for researchers to consider prior to embarking on qualitative research in this context and advocate researchers in this field carefully consider the issues presented on a study-by-study basis.

BACKGROUND: People with intellectual disabilities often present with unique challenges that make it more difficult to meet their palliative care needs.
OBJECTIVE: To define consensus norms for palliative care of people with intellectual disabilities in Europe.
METHODS: Delphi study in four rounds: (1) a taskforce of 12 experts from seven European countries drafted the norms, based on available empirical knowledge and regional/national guidelines; (2) using an online survey, 34 experts from 18 European countries evaluated the draft norms, provided feedback and distributed the survey within their professional networks. Criteria for consensus were clearly defined; (3) modifications and recommendations were made by the taskforce; and (4) the European Association for Palliative Care reviewed and approved the final version.
METHODS: Taskforce members: identified through international networking strategies. Expert panel: a purposive sample identified through taskforce members\' networks.
RESULTS: A total of 80 experts from 15 European countries evaluated 52 items within the following 13 norms: equity of access, communication, recognising the need for palliative care, assessment of total needs, symptom management, end-of-life decision making, involving those who matter, collaboration, support for family/carers, preparing for death, bereavement support, education/training and developing/managing services. None of the items scored less than 86% agreement, making a further round unnecessary. In light of respondents\' comments, several items were modified and one item was deleted.
CONCLUSIONS: This White Paper presents the first guidance for clinical practice, policy and research related to palliative care for people with intellectual disabilities based on evidence and European consensus, setting a benchmark for changes in policy and practice.

A new study suggests there is a lack of consensus or understanding about what patients intend when they fill out Physicians Orders for Life Sustaining Treatment (POLST) forms, and that this likely leads to patients either receiving or not receiving treatment contrary to their wishes. Investigators suggest more training on these issues is needed, and recommend that clinicians take the time to clarify choices during periods of critical illness. A new study found that when presented with a range of clinical scenarios coupled with POLST forms reflecting patient wishes, emergency providers did not often reach a consensus on what actions they would take. Researchers say that \"do not resuscitate\" orders are commonly misinterpreted to mean do not treat, and there are also practice and regional variations in how end-of-life-care documents are interpreted. While a national organization establishes POLST recommendations and sample policies, the documents themselves are established and regulated at the state level, along with training procedures. Experts recommend that hospitals establish quality control procedures to ensure that end-of-life-care documents are prepared and interpreted accurately.

The article sheds light on the way the author\'s scientific views and endeavors in the field of dying, death, and bereavement over 40 years in Germany have been influenced by the work of Robert Kastenbaum. Reconstructing the passage of time, the early years (i.e., the second half of the 1970s), a middle period (i.e., the 1980s and 1990s), and the later years (i.e., from the turn of the century to the present) are outlined. In an anecdotic fashion, two personal encounters with R. Kastenbaum are reported. The article concludes with showing\\consensus and dissention in various respects and finally recounts the author\'s admiration for this outstanding scholar.

The management of patients with end-stage chronic organ failure is an increasingly important topic, since the extraordinary medical and technological advances have significantly reduced mortality and improved quality of life with prolonged survival of end-stage diseases. What should be the plan of care for these patients? Who should bear the responsibility for care? With what targets? These are crucial questions, to which modern medicine should provide convincing answers. The authors of the document explicitly resisted the temptation to draw up guidelines, showing that it is possible to customize medical intervention on the individual patient, keeping it tightly linked to the available knowledge. This is the most relevant aspect of the document: it goes beyond the classical concept of evidence-based medicine choosing to refer to the most dynamic knowledge-based medicine approach.