REVIEW URRENT C OPINION

Palliative sedation for intolerable suffering Marco Maltoni a, Emanuela Scarpi b, and Oriana Nanni b

Purpose of review The purpose of this review is to provide an update on palliative sedation in palliative and end-of-life care. Palliative sedation is the medical procedure used to deal with refractory symptoms in advanced cancer patients when all other specific approaches have failed. Recent findings Palliative sedation, in the strictest sense of the term, is a proportionate (proportionate palliative sedation, PPS) and intrinsically variable procedure used on an individual basis to relieve refractory symptoms in terminally ill patients, without the intention of hastening death. Completely separate from any other end-oflife decision and not intended to hasten death, palliative sedation has been shown not to have a detrimental impact on survival. Summary To maintain palliative sedation as a legitimate clinical procedure from any ethical or clinical point of view, it must be limited to the restricted area for which it was conceived, that is, relief from refractory suffering as deemed necessary by a patient and by an experienced palliative care team. In this way, there is no risk of associating palliative sedation with other end-of-life decisions. Close collaboration is needed between oncologists and palliative care physicians for this clinical procedure. Keywords end-of-life, palliative care, palliative sedation

INTRODUCTION The present article is a 12-month update of a comprehensive review on palliative sedation published in this journal in 2013 [1 ]. Palliative sedation is the medical procedure used to deal with refractory symptoms that are not otherwise manageable with specific antisymptomatic therapies. It comprises a number of clinical, assistential, relational, and ethical aspects that make it a particularly delicate issue. Notwithstanding the considerable body of evidence in the literature supporting the practice, some controversies remain. Although palliative sedation can be performed in various diseases, we will limit our discussion to its application in cancer patients. &

and is a proportional and individually tailored procedure that is not designed to hasten death. It is generally used in terminally ill patients and is completely separate from other end-of-life decisions [2 ]. The ‘most intense’ form of proportionate palliative sedation (PPS) known as deep continuous sedation (DCS) is, therefore, only considered necessary when symptom relief is not obtained using milder forms of sedation and represents the last step of a gradual process. Any wider interpretation of the approach must be considered as a ‘mission creep,’ that is, the expansion of a project or mission beyond its original goals. Furthermore, any procedure used with the intention of hastening death cannot be considered palliative sedation, as this was not its original purpose [2 ]. However, although precise &&

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DEFINITION Palliative sedation has now largely replaced the misleading term ‘terminal sedation.’ It is also widely accepted that the aim of palliative sedation is ‘to relieve intolerable suffering from refractory symptoms,’ and that the only way to achieve this is by reducing consciousness. Palliative sedation is characterized by intrinsic variability (depth of sedation, continuity, drug used, speed of instauration)

a Palliative Care Unit and bUnit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy

Correspondence to Marco Maltoni, MD, Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014 Meldola, Italy. Tel: +39 0543 733332; fax: +39 0543 738803; e-mail: [email protected] Curr Opin Oncol 2014, 26:389–394 DOI:10.1097/CCO.0000000000000097

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KEY POINTS

regarding its definition and partly because of differences in study population selection, its use is becoming more widespread [4,8 ]. Literature data show that the practice of palliative sedation is increasing in hospitals, nursing homes and in the home care setting, with an overall incidence of use in 4–36% of all deaths [8 ,9 ,10,11 ]. However, it is essential that this increase is accompanied by full compliance with current standards of care and accepted palliative sedation guidelines. &

 Palliative sedation is the medical practice used to deal with refractory symptoms that cannot be managed with specific antisymptomatic therapies.  Palliative sedation is an intrinsically proportional and individually monitored practice in which there is no intention to hasten death.  Palliative sedation for psychological distress or existential suffering is an extremely delicate issue.  Palliative sedation must be carried out in concordance with international guidelines.  If performed in a proportional way, palliative sedation does not have a detrimental effect on survival.

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INDICATIONS The symptoms that most often become refractory are delirium, dyspnea, psychological distress/existential suffering, and pain, delirium being the most common cause of palliative sedation [1 ,12,13]. Psychological distress/existential suffering is a highly delicate, complex issue whose characteristics differ from those of physical symptoms. It is not, in fact, limited to the terminal phase, may have a fluctuating and unpredictable course, and is not easily controllable even in otherwise healthy individuals. The decision to introduce palliative sedation for psychological distress/existential suffering should be carefully assessed and regularly reviewed by a multidisciplinary team of experts who focus on contrasting unbearable symptoms, providing psychological support and spiritual guidance, and implementing intermittent rather than ‘continuous’ sedation [14 ,15,16]. A recent Swiss study showed that the attitude of physicians toward sedation is more favorable in the presence of physical symptoms rather than psychological distress/existential suffering [17 ]. Interestingly, prognosis would not seem to affect this attitude as much as the type of suffering. However, using palliative sedation in psychological distress/existential suffering could be seen as an ‘easy’ way of providing palliative care without having to reflect on important aspects of suffering such as those pertaining to its existential nature. The problem also remains as to whether the ‘perception of the lack of a meaningful existence can be treated with sleep’ [18]. &

guidelines exist for the correct practice of palliative sedation, the direct use of DCS without moving through a proportional process and with a full or partial intention of hastening death continues to be reported [3 ]. In that sense, palliative sedation is already DCS from the start, independently of the level of symptom control required. Some even call this form ‘continuous sedation until death’ (CSD), suggesting that the physician chooses a priori to sedate a patient until death without prospectively monitoring the result or modifying the approach as needed on the basis of clinical conditions [4]. So many definitions have been used for DCS/CSD that it is not completely clear what is meant by these terms. A number of ethical justifications concerning CSD have also been called into question [4]. A further ethical concern is the ‘value’ of the sedated person. For some authors, palliative sedation and, in particular, DCS bring the patients to a state wherein they can no longer be considered as a ‘person.’ We, on the contrary, concur with Materstvedt and Bosshard [5], who provide substantial grounds for contesting that deep sedation turns the patient into a ‘living dead-like’ person. Patients can continue to be talked to, wanted, cared for, and loved in a warm human relationship, simply ‘answering’ with their presence and, sometimes, in unexpected ways. Recently, Eastern authors also elaborated the interesting ‘Ring Theory,’ which focuses on the belief that an innate core of personhood (‘individual’ component) remains even when other components of personality (e.g., relational and societal) are severely reduced [6,7 ]. &

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MONITORING Areas to be monitored in palliative sedation are relief of suffering, level of consciousness (depth of sedation), and side-effects of sedation [9 ,19]. The evaluation of results of palliative sedation in end-of-life care is mainly a clinical task for which widely validated tools are used [1 ], for example, the RASS scale (the most widely validated and easy-to-use index) [20 ,21]. However, there is some concern about the reliability of such clinical tools and about &

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PREVALENCE Although palliative sedation is not an easily measurable procedure, partly because of the uncertainties 390

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the fact that some patients may continue to suffer without being able to communicate. Deschepper et al. [9 ] proposed the use of an integrated mixed method to improve the evaluation of palliative sedation comprising a combination of existing observational scales, subjective assessments of caregivers and family, and neuroimaging and/or electrophysiological techniques. Unfortunately, the feasibility of such an approach seems remote in end-of-life care and more appropriate as an area of research. The article nonetheless provides useful indications for carrying out an accurate assessment of palliative sedation in order to avoid the risk of underdiagnosis and undertreatment. However, the monitoring and reporting of palliative sedation results is not a widespread practice: one systematic review reported that only five clinical studies and one guideline-based article included the use of a validated scale [22]. &

IMPACT ON SURVIVAL It has been definitively proven that PPS, when appropriately used to relieve uncontrolled symptoms, does not have a detrimental effect on survival [1 ,12,27 ]. This is also true for DCS when it is correctly performed as the last step of PPS [28]. For some authors, the knowledge that PPS does not impact survival is considered as a fact and does not generate ethical reflection [29]. In our opinion, however, it is difficult to comprehend how the shortening or nonshortening of life can be regarded as an inconsequential issue [1 ]. The absence of an impact on survival also refutes conceptual analyses that tend to equate palliative sedation with euthanasia or other end-of-life decisions hastening death [30]. Furthermore, palliative sedation is the only so-called end-of-life decision that is universally accepted by all ethical codes and all European countries, including southern European regions [31]. &

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DURATION There have been no updates on this topic over the past 12 months. Thus, as revealed previously from a systematic review of the literature, the duration of palliative sedation ranges from 0.8 to 12.6 days [12], with 2–4 days being the most frequent duration [1 ]. &

DRUGS

SEDATION AND EUTHANASIA Palliative sedation and euthanasia are morally distinct practices: the intention of palliative sedation is to relieve unbearable suffering, whereas that of euthanasia is to end the patient’s life. ‘Intention’ is used in the strictest sense of the word, that is, an aim that guides an action rather than the hypothetical awareness and knowledge of possible foreseeable and unforeseeable consequences [2 ]. Bruinsma et al. [32] reported that clinicians were influenced by the way in which they were asked about whether they felt they had hastened death with palliative sedation: 51% replied ‘yes’ to a direct question, whereas 87% responded ‘yes’ to an indirect one. The uncertainty of how to respond would seem to be the result of an inaccurate conception of palliative sedation and of branding it as something it is not. It also indicates a lack of clarity in terms of intention. However, the European Association for Palliative Care (EAPC) has added two more features to the concept of intention: result (in palliative sedation, success is the relief obtained from refractory symptoms, whereas in euthanasia, it is the death of the patient) and procedure (in palliative sedation, this is individualized and closely monitored, with minimum effective doses used, whereas in euthanasia the procedure is standardized and not monitored) [33 ]. Ten Have and Welie [2 ], with the aim of stripping palliative sedation down to its strictest and most appropriate sense, added the following features: terminality, refractory symptoms, proportionality and separation from other end-of-life decisions. This last point is of particular interest because in the past some authors have &&

The majority of authors agree that the drugs used in PPS must be titrated to the minimum level of consciousness reduction needed to make symptoms bearable [9 ]. Midazolam is the preferred drug and the one most widely used, followed by haloperidol and chlorpromazine [12]. However, there is no firm evidence to suggest that one medication commonly used in palliative sedation therapy is superior to any other. In the past few years, some articles have also been published on less frequently used drugs. Dietz et al. [23] examined 33 articles on the efficacy of levomepromazine for the control of palliative symptoms, 15 in the area of palliative sedation. However, as the supporting evidence was limited to open series and case reports, it was not possible to draw any definitive conclusions [23]. Recently, a protocol for the acute control of delirium and agitation suggested the potential efficacy and safety of combining midazolam with haloperidol [24 ]. The use of ketamine in palliative sedation has been hypothesized by Shlamovitz et al. [25], whereas another group published a case report on a patient with end-stage ovarian cancer, peritoneal carcinomatosis, and refractory nausea and vomiting who responded dramatically to the use of dronabinol [26]. &

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included palliative sedation in other end-of-life decisions that have a definite or possibly negative impact on survival [11 ]. &

SEDATION AND HYDRATION Initiating palliative sedation does not automatically mean that parenteral hydration must be interrupted. The continuance/interruption of hydration and the need to start palliative sedation involve two separate decision-making processes. Decisions for or against hydration are often dependent on personal convictions and different care settings (hospital vs. hospice) rather than on clinical conditions. The impact of different doses of parenteral hydration in end-of-life cancer patients was not clearly demonstrated in a recent randomized clinical trial by Bruera et al. [34 ]. The authors, however, hypothesized a number of shortcomings that may have limited the power of their study, concluding that further research is needed into this area [34 ]. Nonetheless, as around 87% of conscious cancer patients report thirst and dry mouth in the final week of life, it is possible that sedated patients who are unable to drink may suffer from thirst or a worsening of CNS symptoms (delirium, confusion, restlessness) without being able to communicate their distress [35]. Conversely, excess hydration may cause water retention symptoms. &&

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RELATIVES A systematic review by Bruinsma et al. [36 ] showed a varying degree of involvement of relatives (60–100%) in the decision-making process and wide acceptance of the palliative sedation procedure, although some families did experience substantial psychological distress. A recent article reported the findings from a study in which an anonymous questionnaire was sent to caregivers (n ¼ 17) of Swiss patients who died while undergoing palliative sedation. Seventy percent of responders felt that palliative sedation was started at the right moment. All noticed a substantial improvement in refractory symptoms, with a mean reduction in the estimated suffering of 6.25 points on a visual analog scale [37]. A study conducted in the Netherlands with focus groups and individual interviews involved 14 relatives of patients who received palliative sedation until death. Although relatives generally agreed with the use of palliative sedation because it contributed to a peaceful dying process, they felt that overall communication between the physician and caregiver was poor [38]. www.co-oncology.com

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Ten Have and Welie [2 ] expressed a concern that the widespread use of palliative sedation could result in palliative care becoming a sort of ‘medicalization of death’ and in silence once again being created around death. Although such a risk exists, it would constitute malpractice, that is, an inappropriate use of a procedure that is the only means of controlling otherwise refractory symptoms.

STAFF NEEDS AND BELIEFS In the study by Arevalo et al. [39], a structured questionnaire was sent to 576 Dutch nurses in different settings. Almost 50% of questionnaires were completed and 71.84% of these reported a case of continuous palliative sedation. Nurses were actively involved in the decision to start sedation in 84% of cases. They were present at the initiation of sedation in 81.40% of cases and reported that physicians were present in 45.22%. The authors concluded that nurses play a key role in the use of continuous palliative sedation. Flemish nurses listed knowledge, skills, and guidelines as essential requisites for the correct implementation of palliative sedation. The majority of nurses did not feel that euthanasia was preferable to palliative sedation and did not support nonvoluntary euthanasia in cases of deeply and continuously sedated patients [40].

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In a study by Rietjens et al. [41], questionnaires submitted to doctors from the United States and the Netherlands revealed that there was much open discussion about palliative sedation between physicians and patients and their families in Holland in order to facilitate advance care planning. Conversely, fewer, later, and less open discussions occurred in the United States. However, the study was fairly small and further research is warranted before any conclusions can be drawn about international differences in this approach to sedation [41].

FRAMEWORK Palliative sedation, a legitimate procedure from any ethical viewpoint, must be performed in accordance with accepted guidelines and decisional frameworks. The EAPC, in particular, regards the use of palliative sedation without previous expert consultation as a highly inadvisable practice and maintains that a multiprofessional palliative care team approach is critical [14 ]. However, one recent &&

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study revealed that Dutch physicians raise both practical and theoretical objections against mandatory consultation [8 ]. Unfortunately, the Dutch view could lead to the misconception that palliative sedation is at least partially aimed at hastening death, or to an empirical misuse of the procedure if it is not fully agreed upon by a team of skilled professionals. &

CONCLUSION Palliative sedation, in its ‘original’ and focused sense, is proportional (PPS) in nature and used to relieve intolerable suffering from refractory symptoms when reducing consciousness is the only way to achieve that goal. It is intrinsically variable in its characteristics (depth, continuity, drug, speed of instauration) and must be carefully monitored to obtain the minimal sedation level needed to control the refractory symptom. Physicians do not initiate palliative sedation with the intention of hastening death. It is generally used in terminally ill patients and is completely separate from other ‘end-of-life decisions’. When performed in this way, even the most intense form of palliative sedation, DCS, has no detrimental impact on survival. DCS is the last step of a progressive approach, used only when milder forms of palliative sedation have had no effect on refractory symptoms. Any wider interpretation of palliative sedation should be considered as ‘mission creep’; if the intention, procedure, and goal of the sedation differ from the above, it cannot be called palliative sedation. Acknowledgements The authors thank Ursula Elbling for editing the manuscript. Disclosure of funding: None. Conflicts of interest The authors declare no competing financial interests.

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Maltoni M, Scarpi E, Nanni O. Palliative sedation in end-of-life care. Curr Opin & Oncol 2013; 25:360–367. This is a complete and recent update on the topic. 2. Ten Have H, Welie JV. Palliative sedation versus euthanasia: an ethical && assessment. J Pain Symptom Manage 2014; 47:123–136. This is an in-depth reflection on the characteristics of palliative sedation and euthanasia. 3. Sterckx S, Raus K, Mortier F. Continuous sedation at the end-of-life: ethical, & clinical, and legal perspectives. Cambridge, UK: Cambridge University Press; 2013. This is a recent book offering different perspectives on palliative sedation, but focusing mainly on the philosophy of DCS and CSD.

4. Rys S, Mortier F, Deliens L, et al. Continuous sedation until death: moral justifications of physicians and nurses–a content analysis of opinion pieces. Med Healthcare Philos 2013; 16:533–542. 5. Materstvedt JL, Bosshard G. Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects. Lancet Oncol 2009; 10:622–627. 6. Krishna LK, Alsuwaigh R, Miti PT, et al. The influence of the family in conceptions of personhood in the palliative care setting in Singapore and its influence upon decision making. Am J Hosp Palliat Care 2013. [Epub ahead of print] 7. Krishna LK. Personhood within the context of sedation at the end of life in & Singapore. BMJ Case Rep 2013. [Epub ahead of print] This is a clear statement on the human dignity of the sedated patient. 8. Koper I, van der Heide A, Janssens R, et al. Consultation with specialist & palliative care services in palliative sedation: considerations of Dutch physicians. Support Care Cancer 2014; 22:225–231. Palliative sedation requires a skilled palliative team approach. Different organizational models run the risk of providing low-quality care. 9. Deschepper R, Laureys S, Hachimi-Idrissi S, et al. Palliative sedation: why we & should be more concerned about the risks that patients experience an uncomfortable death. Pain 2013; 154:1505–1508. An appropriate palliative sedation culture needs to be developed. 10. Anquinet L, Rietjens JA, Seale C, et al. The practice of continuous deep sedation until death in Flanders (Belgium), the Netherlands, and the UK: a comparative study. J Pain Symptom Manage 2012; 44:33–43. 11. Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C. Trends in & end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012; 380:908–915. This is an important epidemiologic overview. 12. Maltoni M, Scarpi E, Rosati M, et al. Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 2012; 30:1378–1383. 13. Kang JH, Shin SH, Bruera E. Comprehensive approaches to managing delirium in patients with advanced cancer. Cancer Treat Rev 2013; 39: 105–112. 14. Cherny N, Radbruch L. The Board of the European Association for Palliative && Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23: 581–593. These are the European guidelines for palliative sedation. Sound guidelines are needed in order to guarantee appropriate palliative sedation. 15. Cherny NI, Portenoy RK. Sedation in the management of refractory symptoms:guidelines for evaluation and treatment. J Palliat Care 1994; 10:31– 38. 16. Kirk TW, Mahon MM. Palliative Sedation Task Force of the National Hospice and Palliative Care Organization Ethics Committee. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. J Pain Symptom Manage 2010; 39:914–923. 17. Beauverd M, Bernard M, Currat T, et al. French Swiss physicians’ attitude & toward palliative sedation: influence of prognosis and type of suffering. Palliat Support Care 2013. [Epub ahead of print] There is an intrinsic difficulty in performing palliative sedation for existential distress and this topic warrants further consideration. 18. Sadler K. Palliative sedation to alleviate existential suffering at end-of-life: insight into a controversial practice. Can Oncol Nurs J 2012; 22:195– 199. 19. Dean MM, Cellarius V, Henry B, et al. (Canadian Society of Palliative Care Physicians Taskforce). Framework for continuous palliative sedation therapy in Canada. J Palliat Med 2012; 15:870–879. 20. Arevalo JJ, Brinkkemper T, van der Heide A, et al. AMROSE Site Study Group. && Palliative sedation: reliability and validity of sedation scales. J Pain Symptom Manage 2012; 44:704–714. This is a rigorous study on the scales used to measure palliative sedation. 21. Benı´tez-Rosario MA, Castillo-Padro´s M, Garrido-Bernet B, et al. Appropriateness and reliability testing of the modified Richmond Agitation-Sedation Scale in Spanish patients with advanced cancer. J Pain Symptom Manage 2013; 45:1112–1119. 22. Brinkkemper T, van Norel AM, Szadek KM, et al. The use of observational scales to monitor symptom control and depth of sedation in patients requiring palliative sedation: a systematic review. Palliat Med 2013; 27:54–67. 23. Dietz I, Schmitz A, Lampey I, Schulz C. Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review. BMC Palliat Care 2013; 12:2. 24. Gonc¸alves F, Almeida A, Teixeira S, et al. A protocol for the acute control of & agitation in palliative care: a preliminary report. Am J Hosp Palliat Care 2012; 29:522–524. This is an interesting report on a combination of drugs to relieve agitation. 25. Shlamovitz GZ, Elsayem A, Todd KH. Ketamine for palliative sedation in the emergency department. J Emerg Med 2013; 44:355–357. 26. Hernandez S, Sheyner I, Stover K, Stewart J. Dronabinol treatment of refractory nausea and vomiting related to peritoneal carcinomatosis. Am J Hosp Palliat 2013. [Epub ahead of print]

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Supportive care 27. Barathi B, Chandra PS. Palliative sedation in advanced cancer patients: does it shorten survival time? – a systematic review. Indian J Palliat Care 2013; 19:40–47. This is an interesting confirmatory review highlighting the lack of impact of palliative sedation on survival. 28. Maltoni M, Scarpi E, Rosati M, et al. Reply to E. Schildmann et al. J Clin Oncol 2012; 30:4177–4178. 29. Rys S, Deschepper R, Mortier F, et al. The moral difference or equivalence between continuous sedation until death and physician-assisted death: word games or war games? A qualitative content analysis of opinion pieces in the indexed medical and nursing literature. J Bioeth Inq 2012; 9:171–183. 30. Lipuma SH. Continuous sedation until death as physician-assisted suicide/ euthanasia: a conceptual analysis. J Med Philos 2013; 38:190–204. 31. Menaca A, Evans N, Andrew E, et al. End-of-life care across Southern Europe: a critical review of cultural similarities and differences between Italy, Spain and Portugal. Crit Rev Oncol Hematol 2012; 82:387–401. 32. Bruinsma SM, Rietjens JA, Swart SJ, et al. Estimating the potential lifeshortening effect of continuous sedation until death: a comparison between two approaches. J Med Ethics 2013. [Epub ahead of print] 33. Materstvedt LJ, Clark D, Ellershaw J, et al. Euthanasia and physician assisted && suicide: a view from an EAPC Ethics Task Force. Palliat Med 2003; 17:97–101. This is the pivotal article from the Ethical Task Force of the European Association for Palliative Care in which the intrinsic differences in intention, procedure, and results between palliative sedation and euthanasia are reported. This is the fundamental work on the ethics of palliative sedation. &

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34. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2013; 31:111–118. This is a high-level study on the pros and cons of hydration at the end-of-life. 35. Beland P. Ethical issues around continuous deep sedation without hydration. Nurs Times 2012; 108:22–25. 36. Bruinsma SM, Rietjens JA, Seymour JE, et al. The experiences of relatives with && the practice of palliative sedation: a systematic review. J Pain Symptom Manage 2012; 44:431–445. This is a scientific study on the experience of family members when their loved one is sedated. 37. Vayne-Bossert P, Zulian GB. Palliative sedation: from the family perspective. Am J Hosp Palliat Care 2013; 30:786–790. 38. Bruinsma S, Rietjens J, van der Heide A. Palliative sedation: a focus group study on the experiences of relatives. J Palliat Med 2013; 16: 1–7. 39. Arevalo JJ, Rietjens JA, Swart SJ, et al. Day-to-day care in palliative sedation: survey of nurses’ experiences with decision-making and performance. Int J Nurs Stud 2013; 50:613–621. 40. Gielen J, Van den Branden S, Van Iersel T, Broeckaert B. Flemish palliativecare nurses’ attitudes to palliative sedation: a quantitative study. Nurs Ethics 2012; 19:692–704. 41. Rietjens JA, Voorhees JR, van der Heidi A, Drickamer MA. Approaches to suffering at the end of life: the use of sedation in the USA and Netherlands. J Med Ethics 2014; 40:235–240. &&

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Palliative sedation for intolerable suffering.

The purpose of this review is to provide an update on palliative sedation in palliative and end-of-life care. Palliative sedation is the medical proce...
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