palliative sedation

姑息性镇静
  • 文章类型: Case Reports
    我们想回应我们从同事那里收到的关于在家安乐死后器官捐赠的案例报告的评论。我们回复他们关于医疗和法律方面的陈述,并提供有关我们对知情同意的观点的更多信息。
    We would like to respond to the comment we received from our colleagues on our case report about organ donation after euthanasia starting at home. We reply to their statements on medical and legal aspects, and provide more information on our view of informed consent.
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  • 文章类型: Journal Article
    背景:临终患者可能会出现难治的疼痛症状,谵妄,呕吐和呼吸困难是最常见的。姑息镇静可以被认为是缓解一种或多种难治性症状的最后选择。只有有限数量的(定性)研究探索镇静患者亲属及其医疗保健专业人员(HCP)的经历。本研究方案的目的是:1)引出接受姑息性镇静治疗的患者的丧亲亲属和医疗保健专业人员的经验;2)探索在5个护理环境中开始姑息性镇静的决策过程的理解。欧洲国家。
    方法:本研究方案是更大的HORIZON2020姑息镇静项目的一部分。组织案例研究方法将用于指导研究设计。总的来说,将在五个欧洲国家(每个国家10个)进行50例。一个病例涉及与一名亲属和一名密切参与护理的HCP的半结构化访谈,该患者在临终时接受了某种姑息性镇静。已故患者的亲属和医疗保健专业人员参与了一项在医院病房护理的镇静患者的关联观察队列研究,将招募姑息治疗单位和收容所。将使用框架分析方法对数据进行分析。第一个完整案例将由所有研究人员在使用预先准备好的代码书翻译成英文后进行分析。之后,将组织两个月一次的会议来协调数据分析。
    结论:该研究旨在更好地了解亲属和专业护理人员在不同环境和国家/地区的姑息镇静方面的经验。一些限制是:1)主题的敏感性可能会阻止一些亲戚参与,2)由于数据收集和分析将由5个国家的至少5个不同的研究人员进行,可能会出现一些差异,这可能会使比较案例变得困难,但是使用严格的方法可以将这种风险降至最低。
    BACKGROUND: Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries.
    METHODS: This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis.
    CONCLUSIONS: The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.
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  • 文章类型: Journal Article
    死于COVID-19的呼吸困难患者接受阿片类药物和苯二氮卓类药物治疗。在某些情况下,患者在生命结束时可能会出现难治性呼吸困难。姑息性镇静可用于减轻此类患者的痛苦。我们描述了两名在三级医院接受严重COVID-19肺炎治疗的患者。尽管使用了大剂量阿片类药物和苯二氮卓类药物,但两者都出现了顽固性的呼吸困难危机。这导致他们需要在普通病房中使用皮下苯巴比妥(苯巴比妥)进行姑息性镇静。我们概述了在COVID-19相关呼吸困难中使用姑息性镇静的临床考虑。特别是,我们讨论证据,在COVID-19患者中使用苯巴比妥进行姑息性镇静的益处和局限性。
    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.
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  • 文章类型: Journal Article
    姑息镇静可以被认为是治疗难以忍受的“最后手段”,终末期患者的难治性症状或痛苦。目的是缓解症状,而不是像安乐死那样诱发死亡。这种治疗可能是姑息治疗领域最具挑战性的治疗选择之一,涉及道德和实践问题。尽管如此,研究表明,这是一种安全和有价值的治疗方法,通常不会缩短患者的寿命。由于瑞士的患者有协助自杀的合法选择,姑息镇静是一种越来越重要的替代方法。据报道,在瑞士接受姑息治疗的所有患者中,有17.5%使用姑息镇静。使这个国家成为使用这种治疗方法最多的人。这篇叙述性综述的目的是讨论姑息镇静中的伦理和实践问题,特别关注瑞士的经验。指示,伦理考虑,讨论了药物的选择和持续时间。决策应基于坚实的指导方针。如果正确使用,姑息镇静是姑息治疗中重要且有用的工具,以提供良好的症状缓解。
    Palliative sedation can be considered as \"the last resort\" in order to treat unbearable, refractory symptoms or suffering in end-of-life patients. The aim is symptom relief and not to induce death as in the case of euthanasia. The treatment might be one of the most challenging therapeutic options in the field of palliative care, involving both ethical and practical issues. Still, studies have shown that it is a safe and valuable treatment and in general does not shorten the life of the patient. Since patients in Switzerland have the legal option of assisted suicide, palliative sedation is an alternative that has become increasingly important. The use of palliative sedation was reported in 17.5% of all patients admitted to palliative care in Switzerland, making the country of those with the highest use of this treatment. The aim of this narrative review is to discuss ethical and practical issues in palliative sedation, with specific focus on experiences from Switzerland. Indications, ethical considerations, drugs of choice and duration are discussed. Decision making should be based on solid guidelines. When used correctly, palliative sedation is an important and useful tool in palliative care in order to provide good symptom relief.
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  • 文章类型: Case Reports
    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.
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  • 文章类型: Journal Article
    背景:在意大利,父母双方都有父母的责任,因此,他们有权给予或拒绝同意他们的孩子的医疗程序。
    方法:本报告一例5岁男童诊断为右侧肾上腺神经母细胞瘤,他接受了几次化疗,延长了他的寿命,直到10岁。仅要求父母知情同意治疗,不考虑未成年人的意愿,甚至当他要求增加止痛药而不是其他姑息治疗时也没有。
    结果:作者认为,根据意大利关于知情同意的新立法来研究此案,并验证其是否促进未成年人更多地参与医疗保健选择,这很有趣。鉴于获得知情同意的问题变得越来越广泛和复杂。
    结论:此处审查的案例表明,意大利现行立法,甚至包括引入的修改,不允许未成年人具体积极参与,尤其是那些12岁以下的人,在讨论他们健康的选择时,即使是关于生命终结的选择,甚至当未成年人表现出成熟的鉴别能力时也没有。
    BACKGROUND: In Italy, both parents have parental responsibility, so they have the power to give or withhold consent to medical procedures on their children.
    METHODS: The present work reports the case of a 5-year-old boy diagnosed with neuroblastoma in the right adrenal loggia, who underwent several chemotherapy treatments that prolonged his life until the age of 10. Informed consent for treatments was requested exclusively of the parents, without taking into consideration the minor\'s will, not even when he asked for increased pain relief medication instead of other palliative treatments.
    RESULTS: The authors thought it interesting to examine the case in the light of new Italian legislation on informed consent and to verify whether it promotes greater participation of minors in healthcare choices, given that the issue of acquisition of informed consent is becoming increasingly broad and complex.
    CONCLUSIONS: The case examined here indicates that current Italian legislation, even including the modifications introduced, does not allow for concrete and active participation of minors, especially those under the age of 12, in the discussion of choices about their health, not even in choices regarding the end of life, and not even when the minor manifests a mature capacity for discernment.
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  • 文章类型: Journal Article
    Sedative drugs are used to improve comfort in dying patients but have been accused of shortening survival by reducing patients\' ability to maintain nutrition and hydration. However, as part of the dying process, patients in the last days of life often have impaired conscious levels and an inability to maintain oral intake.
    To establish whether the decline in oral intake is related to the use of midazolam in the last week of life.
    This is a retrospective case note review.
    The data were obtained from nursing records and medication charts of 125 consecutive hospice inpatients who died at a hospice in South London.
    A total of 72 patients received midazolam on one or more days within the last 7 days of life (midazolam group) and 49 patients received no midazolam (control group).
    Mean oral intake was reduced 7 days prior to death and declined sequentially over subsequent days in both patient groups. More patients required midazolam as death approached and most patients received midazolam for less than 3 days. Mean doses of midazolam used were low. Patients in the midazolam group had lower oral intake than those in the control group, but this association does not indicate causation.
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  • 文章类型: Journal Article
    OBJECTIVE: Continuous sedation at the end of life is an end-of-life practice that has gained considerable attention in the international literature. Nevertheless, significant confusion persists, even on how to label or define the practice. Several different terms and definitions exist, and these are often non-neutral and indicative of one\'s normative position on sedation at the end of life. This is problematic for two reasons. First, the use of such value-laden terms or definitions of continuous sedation may make it difficult, if not impossible, to agree on the facts surrounding continuous sedation. Second, including normative criteria in a definition can lead one to make disguised circular or tautological statements.
    METHODS: This paper identifies commonly used terms and definitions and demonstrates how particular elements present in these are value-laden and can influence the ethical evaluation of continuous sedation at the end of life.
    RESULTS: Two commonly used terms, \'palliative sedation\' and \'terminal sedation\', have been strongly criticized. We propose to use another, more descriptive term, namely \'continuous sedation at the end of life\'. As regards the different definitions of sedation, some are general, but most contain very specific elements, thereby clearly limiting the number of cases that are covered by the definition. Some definitions of sedation include the intention one should (not) have, the possible indications for the practice, and the type of patients the practice should be reserved for.
    CONCLUSIONS: Including value-laden elements in the very definition of a clinical practice runs the risk of pre-empting a proper normative debate about the practice. We explain why this is the case and why it is problematic, and we propose an alternative, descriptive, definition that seeks to avoid these problems.
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  • 文章类型: Journal Article
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  • 文章类型: Case Reports
    我们介绍了一名34岁的Klippel-Feil综合征女性,该女性出现了病因不明的进行性广泛性肌张力障碍,导致顽固性疼痛,尽管积极的药物和手术干预。最终,需要姑息镇静来减轻痛苦。在这里,我们描述了道德考虑,包括定义镇静,在未定义的神经退行性疾病的背景下确定预后,以及同时使用可能延长或改变寿命终点轨迹的治疗方法。我们重点介绍相关文献以及如何将其应用于具有挑战性和独特的临床情况。最后,我们讨论了在实施姑息镇静时需要专家多学科参与,并说明需要解释程序和规则,以提供以患者为中心的最佳护理计划.
    We present the case of a 34-year-old woman with Klippel-Feil syndrome who developed progressive generalized dystonia of unclear etiology, resulting in intractable pain despite aggressive medical and surgical interventions. Ultimately, palliative sedation was required to relieve suffering. Herein, we describe ethical considerations including defining sedation, determining prognosis in the setting of an undefined neurodegenerative condition, and use of treatments that concurrently might prolong or alter end-of-life trajectory. We highlight pertinent literature and how it may be applied in challenging and unique clinical situations. Finally, we discuss the need for expert multidisciplinary involvement when implementing palliative sedation and illustrate that procedures and rules need to be interpreted to deliver optimal patient-centered plan of care.
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