2019; Volume 20, No 7, July
Lessons from the Literature
Under My Microscope
Dr. Tania Pastrana
IAHPC research advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
Clinical Patterns of Continuous and Intermittent Palliative Sedation in Patients with Terminal Cancer: A descriptive, observational study
YW Won, HS Chun, M Seo, RB Kim, JH Kim, JH Kang. J Pain Symptom Manage, 2019; 58(1): 65-71.
DOI: 10.1016/j.jpainsymman.2019.04.019
Palliative sedation is ‘a widely used term to describe the intentional administration of sedatives to reduce a dying person’s consciousness to relieve intolerable suffering from refractory symptoms.’1 Despite current guidelines and extended experience, ethical and practical controversial questions about the sedation seem to continue.
The systematic observation of the practice can surely offer useful insights. This Korean team, lead by Dr. Kang, looked into clinical outcomes of intermittent and continuous palliative sedation in a clinical setting. The team reviewed the cases of 306 inpatients in a hospice unit. According to the unit’s protocol, midazolam was used as the first medication for palliative sedation, followed by propofol and phenobarbital.
The study revealed that 29% of the patients required palliative sedation — mostly due to delirium, dyspnea, or pain — and 89% of symptoms were successful relieved with midazolam (median: 2mg/h). For those whom midazolam failed, 75% received propofol (median: 2mg/kg/h) and phenobarbital.
The survival time between patients with and without sedation was similar. Patients with intermittent palliative sedation survived a median of six days; those with continuous palliative sedation survived a median of one day (P < 0.001). The difference was presumed to be due to the worse general condition of these patients.
In patients with delirium, consciousness levels were significantly improved after intermittent palliative sedation, as compared with those without (41.7% vs 16.7%, P = 0.002).
The authors concluded that ‘the refractory symptoms of end-of-life patients with cancer can ultimately be relieved with various medications for [palliative sedation]. Intermittent palliative sedation may improve the consciousness level of patients with delirium.’
Reference
1 Twycross R. Reflections on palliative sedation. Palliat Care. Research and Treatment, 2019; 12: 1-16
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Media Watch: On Humanitarian Crises
Palliative care is entering the ‘culture’ of humanitarian organizations. Morbidity and mortality caused by non-communicable diseases are about to overtake infectious diseases in adults, and the epidemiology of diseases is shifting toward chronic conditions even in low-income countries where disasters and armed conflicts are common.
Palliative care in universal health coverage: What about humanitarian emergency assistance?
INTERNATIONAL JOURNAL OF PUBLIC HEALTH, 2019; 64(4): 475-476. The recent Lancet Commission report on palliative care (PC) and pain relief in universal health coverage concentrates on injuries and acute conditions.1 Humanitarian organisations are less experienced in managing chronic conditions with long courses that are steeply increasing the number of patients who need PC. Little is known about how to integrate PC or advanced pain control into medical emergency assistance projects,2 but the World Health Organization is extending its guidelines on PC to cover emergency assistance,3 and the new edition of the Sphere Handbook, a collection of recommendations and standards for humanitarian assistance, contains a chapter on PC.4
DOI: 10.1007/s00038-018-1184-5
- Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission Report. The Lancet, 2018; 391(10128): 1391-1454.
- What do humanitarianemergency organizations do about palliative care? A systematic review. Medicine, Conflict & Survival, 2017; 33(4): 263-272.
- Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises. World Health Organization, September 2018.
- The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response—2018 Edition. Sphere Association, 2018. [The section on palliative care begins on p. 345.]
How to talk with dying patients and their families after disasters and humanitarian crises: A review of available tools and guides for disaster responders
INTERNATIONAL JOURNAL OF HUMANITARIAN ACTION | Online – 22 May 2019 – In responding to those affected by sudden onset disasters and chronic humanitarian crises, disaster responders and humanitarian aid workers will face the challenge of caring for dying patients. While medical intervention may be severely limited or constrained, bearing witness by listening and being able to compassionately communicate with such victims and their families is an important skill. This review examines the current literature on communication training and palliative care (PC) skills for disaster workers and offers a menu of communication tools including guidelines developed for administering PC in non-disaster settings that can be used by both disaster responders and humanitarian aid workers.
DOI: 10.1186/s41018-019-0059-6
Palliative care training for work in an austere environment after a natural disaster
PREHOSPITAL & DISASTER MEDICINE, 2019; 34(1): S54. Challenges to the care of the dying during a disaster include a loss of medical infrastructure and scarce medical or physical resources. Palliative care (PC) training for non-PC specialists can be instructive for the development of PC training for medical care responders after disasters. Applying standards, identifying goals-of-care for the expectant patient, communication to the patient and family members, if available, can help reduce suffering of this group of devastatingly vulnerable patients. In addition, peer support, on-site discussions and debriefing, and problem-solving when resources are limited will help alleviate moral distress among the providers.
DOI: 10.1017/S1049023X19001250
Media Watch, published by Barry R. Ashpole, a Canadian communications consultant and educator, monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.