Palliative sedation in clinical scenarios: results of a modified Delphi study.

PURPOSE: To explore the consistency in international expert opinions about palliative sedation. METHODS: A modified electronic-Delphi procedure was carried out in two rounds. On hundred nine eligible experts were identified from their publications in MEDLINE related with terminal delirium, dyspnea and palliative sedation in the last 3 years. Delphi study included three vignettes of cancer patients and two non-cancer patients, with an estimated survival of days and severe suffering secondary to refractory complications. Experts were asked about whether they would perform continuous sedation and sedation level (described as Richmond Agitation Sedation Scale or defined as patient/family report of symptom relief). Consensus was considered when 70% or more of the experts agreed on a certain topic. RESULTS: Thirty-four and 27 panellists completed the 2 Delphi rounds, respectively. Participants were from the USA, Canada, Europe, Australia and Asia. One hundred per cent, 97% and 88% of the respondent agreed use of sedatives, continuously or temporary, in cases of refractory delirium, dyspnea secondary to lung cancer and GOLD IV-EPOC. There were discrepancies for cases of dementia and psycho-existential suffering. Expert selection of continuous palliative sedation was 93% for delirium, 41% for cancer dyspnea, 66% for EPOC dyspnea, 22% for agitation/pain in dementia and 19% for existential suffering. Responses about types and levels of sedation did not achieve consensus in any cases. CONCLUSIONS: The Delphi study failed to reach consensus in continuous palliative sedation and sedation levels for patients with refractory symptoms described in hypothetical clinical scenarios.

A systematic review of specialised palliative care for terminal patients: which model is better?

There is evidence of improved effectiveness of specialised palliative care for terminally ill patients in comparison to conventional care. However, there is uncertainty about which model is better. The objective of this systematic review was to identify studies that compare specialised palliative care models between them assessing their effectiveness or cost-effectiveness. We searched studies published between 2003 and 2006 in several electronic databases and updated the search in MEDLINE up to 2008. Papers published before 2003 were identified by means of previous systematic reviews and manual search. Studies with broad designs comparing two or more specialised palliative care programmes in adults with terminal illness were selected. Six systematic reviews, three studies on effectiveness and one cost study were included. All systematic reviews drew the conclusion that specialised palliative care is more effective than conventional care. The methodological limitations of the original studies and the heterogeneity of programmes did not allow to draw conclusions about whether a specific model of specialised palliative care is more or less effective or cost-effective than other.