Reporting of Palliative Sedation and Use of Opioids at the End of Life in a Belgian University Hospital: A Pilot Study.

Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as "slow/passive euthanasia"). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ≥18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation.

Systematic screening for distress in oncology practice using the Distress Barometer: the impact on referrals to psychosocial care.

PURPOSE: This study evaluates how patterns of psychosocial referral of patients with elevated distress differ in a 'systematic screening for distress' condition versus a 'usual practice' condition in ambulatory oncology practice. METHODS: The psychosocial referral process in a 2-week usual practice (N=278) condition was compared with a 2-week 'using the Distress Barometer as a screening instrument' (N=304) condition in an outpatient clinic with seven consulting oncologists. RESULTS: Out of all distressed patients in the usual practice condition, only 5.5% of patients detected with distress were actually referred to psychosocial counselling, compared with 69.1% of patients detected with distress in the condition with systematic screening using the Distress Barometer. Only 3.7% of patients detected with distress in the usual practice condition finally accepted this referral, compared with 27.6% of patients detected with distress in the screening condition. CONCLUSIONS: Using the Distress Barometer as a self-report screening instrument prior to oncological consultation optimises detection of elevated distress in patients, and this results in a higher number of performed and accepted referrals, but cannot by itself guarantee actual psychosocial referral or acceptance of referral. There is not only a problem of poor detection of distress in cancer patients but also a need for better decision-making and communication between oncologists and patients about this issue.