Pain in terminal dementia

Palliative Medicine

Background: Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed. Aim: To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured. Design: Integrative review of most recent empirical research. Data sources: Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010–2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness. Results: Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agi...

2017

Context. Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning. Objectives. This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life. Methods. A prospective multicenter observational study was performed in six Dutch hospices and three nursing homebased palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed. Results. A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statisticall...

Palliative Medicine, 2010

This is a systematic review examining the management of opioid-induced central side effects. It has been conducted as part of a larger European Palliative Care Research collaborative review into the use and role of opioids in cancer pain. The review process identified 26 studies that met the inclusion criteria. The overall quality of the data was low and the few recommendations that can be made are weak and require confirmatory studies. The main central side effects examined were sedation, cognitive failure, sleep disturbance and myoclonus. Overall there is limited evidence for the use of methylphenidate in counteracting opioid-induced sedation and cognitive disturbance. No clear recommendations can be made concerning other individual drugs for the management of any of the central side effects examined. Given the lack of available data from this review there need to be further prospective controlled trials to confirm or refute these findings.

Journal of Pain and Symptom Management, 2008

The overall aim of this paper is to systematically review the following important aspects of palliative sedation: prevalence, indications, survival, medication, food and fluid intake, decision making, attitudes of physicians, family experiences, and efficacy and safety. A thorough search of different databases was conducted for pertinent research articles published from 1966 to June 2007. The following keywords were used: end of life, sedation, terminal sedation, palliative sedation, refractory symptoms, and palliative care. Language of the articles was limited to English, French, German, and Dutch. Papers reporting solely on the sedatives used in palliative care, without explicitly reporting the prevalence or intensity of sedation, and papers not reporting on primary research (such as reviews or theoretical articles) were excluded. Methodological quality was assessed according to the criteria of Hawker et al. (2002). The search yielded 130 articles, 33.8% of which were peer-reviewed empirical research studies. Thirty-three research papers and one thesis were included in this systematic review. This review reveals that there still are many inconsistencies with regard to the prevalence, the effect of sedation, food and fluid intake, the possible life-shortening effect, and the decision-making process. Further research to clarify all of this should be based on multicenter, prospective, longitudinal, and international studies that use a uniform definition of palliative sedation, and valid and reliable instruments. Only through such research will it be possible to resolve some of the important ethical issues related to palliative sedation.

Journal of Palliative Medicine, 2022

In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making

Palliative Medicine, 2009

Palliative sedation (PS) is the use of medications to reduce consciousness for the relief of intolerable and refractory symptoms, in patients with limited life expectancy. The ethical justification of palliative sedation is based upon the principles of double effect, autonomy and proportionality. 1 Double effect is predicated upon the primary intent being to relieve suffering, despite potential foreseeable, but unintended, adverse effects. Proportionality is based upon the use of PS in the face of intolerable distress as a 'therapy of last resort', when all other potentially less harmful options have been expended or are inappropriate. 1 PS is neither slow euthanasia nor physician-assisted suicide. Both of these practices involve the specific intent to end life, the deliberate use of lethal doses of sedation drugs, or non-therapeutic escalation of doses disproportionate to symptom distress. PS does not shorten life overall (when implemented in specialist palliative care units), despite the expected risk of individual complications (e.g. respiratory or hemodynamic compromise, aspiration, or venous thromboembolism). Sedative drugs first appeared in modern medicine in the 19th century, with bromide and chloral hydrate. Barbiturates were introduced in 1903, and benzodiazepines in 1959. The first descriptions of sedation for symptom control in advanced disease were published in 1990-1991. 2 The early literature described a wide range in prevalence, indications and clinical practices. The prevalence in these reports ranged from 16% to over 50%. 2 Indications included agitation and restlessness, pain, delirium, respiratory distress, myoclonus, and psychological symptoms. Drugs used for sedation included benzodiazepines, antipsychotics and barbiturates. Despite a number of prospective studies and published guidelines, evidence upon which to base practice has remained limited and controversial issues persist. These include almost every aspect of PS; the definition and terminology (palliative versus terminal), the types of sedation included under this term (intermittent versus continuous, light versus deep), the indications (physical or existential distress), the use of artificial hydration and nutrition, and the ethical basis and differentiation from euthanasia.

Palliative Medicine, 2009

The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

Reviews, 1996

Journal of pain and …, 2007

Topicos, 2024

Resumen: In questo saggio vorrei mostrare che Platone scrisse il Sofista per tematizzare una questione cruci-ale, che in tale dialogo è problematizzata per la prima volta: l’essere, la realtà delle cose, non si presenta a noi direttamente e chiaramente. Per comprendere la realtà delle cose, che sembra evidente e invece è sfuggente, è necessario inseguirla come una preda che si nasconde. Se è necessario cercare l’essere per catturarlo è perché spesso quel che cogliamo non è l’essere ma l’apparire. Il cuore del dialogo – la sezione sull’immagine – è la definizione dello statuto dell’apparenza. Il mio punto è che non è possibile spiegare la natura del non essere senza legare il discorso sul non essere al discorso sull’immagine. Nella sezione sull’immagine è presentata la natura contraddittoria dell’eidolon. Lo Straniero, che in questa sezione è il portavoce del sofista, gioca il ruolo dell’interrogante e conduce Teeteto ad ammettere che l’immagine non soltanto non è un ente, ma è il contrario dell’ente (Sph. 240b5-6). Quando, in Sph. 257b3-4, lo Straniero dice che “quando diciamo ‘non essere’ non di-ciamo qualcosa di contrario all’essere, ma soltanto di diverso da esso”, egli si riferisce – correggendolo – a ciò che il sofista ha detto nella sezione sull’immagine. Io credo che “ciò che è diverso dall’essere” sia precisamente l’apparire, il cui statuto aporetico è stato sottolineato nella sezione sull’immagine. La mia tesi è che il non es-sere è il phantasma, il darsi dell’essere alla percezione degli umani non direttamente, non chiaramente, non veramente, ma sotto una falsa sembianza.