Influence of Deep Sedation in Intensive Care Medicine Memories of Critical COVID-19 Survivors.

Introduction: Critical care survivors sustain a variety of sequelae after intensive care medicine (ICM) admission, and the Coronavirus Disease 2019 (COVID-19) pandemic has added further challenges. Specifically, ICM memories play a significant role, and delusional memories are associated with poor outcomes post-discharge including a delayed return to work and sleep problems. Deep sedation has been associated with a greater risk of perceiving delusional memories, bringing a move toward lighter sedation. However, there are limited reports on post-ICM memories in COVID-19, and influence of deep sedation has not been fully defined. Therefore, we aimed to evaluate ICM-memory recall in COVID-19 survivors and their relation with deep sedation. Materials/Methods: Adult COVID-19 ICM survivors admitted to a Portuguese University Hospital between October 2020 and April 2021 (second/third "waves") were evaluated 1 to 2 months post-discharge using "ICU Memory Tool," to assess real, emotional, and delusional memories. Results: The study included 132 patients (67% male; median age = 62 years, Acute Physiology and Chronic Health Evaluation [APACHE]-II = 15, Simplified Acute Physiology Score [SAPS]-II = 35, ICM stay = 9 days). Approximately 42% received deep sedation (median duration = 19 days). Most participants reported real (87%) and emotional (77%) recalls, with lesser delusional memories (36.4%). Deeply sedated patients reported significantly fewer real memories (78.6% vs 93.4%, P = .012) and increased delusional memories (60.7% vs 18.4%, P < .001), with no difference in emotional memories (75% vs 80.4%, P = .468). In multivariate analysis, deep sedation had a significant, independent association with delusional memories, increasing their likelihood by a factor of approximately 6 (OR = 6.274; 95% confidence interval = 1.165-33.773, P = .032), without influencing real (P = .545) or emotional (P = .133) memories. Conclusions: This study contributes to a better understanding of the potential adverse effects of deep sedation on ICM memories in critical COVID-19 survivors, indicating a significant, independent association with the incidence of delusional recalls. Although further studies are needed to support these findings, they suggest that strategies targeted to minimize sedation should be favored, aiming to improve long-term recovery.

Mental health impact of admission to the intensive care unit for COVID-19.

The pandemic caused by Covid-19 has long term ramifications for many, especially those patients who have experienced an intensive care unit (ICU) admission including ventilation and sedation. This paper will explore aspects of care delivery in the ICU regarding the current pandemic and the impact of such on the mental health of some of these patients. Post discharge, patients will be returning to a very different community incorporating social distancing, and in some cases, social isolation and/or shielding. Many may experience a multitude of physical and mental health complications which can ultimately impact upon each other, therefore a bio-psycho-pharmaco-social approach to discharge, case management, risk assessment and positive behavioural support planning is recommended.

Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective.

OBJECTIVE: Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD. METHOD: A narrative literature review (2000-2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress. RESULTS: (1) Definitions of "refractory symptom," "refractory psychological distress," and "refractory existential distress" are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice. SIGNIFICANCE OF RESULTS: Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.

Moral identity and palliative sedation: A systematic review of normative nursing literature.

BACKGROUND: In the last two decades, nursing authors have published ethical analyses of palliative sedation-an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. RESEARCH AIM: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses' moral identities are portrayed within this literature. RESEARCH DESIGN: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher's Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors' portrayal of the nursing role. FINDINGS: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses' proximity to patients and families in end-of-life care. DISCUSSION AND CONCLUSION: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples' moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.

Sedación paliativa en una unidad de cuidados paliativos de un hospital de tercer nivel: ¿es habitual el sufrimiento emocional o existencial? / Palliative sedation in a palliative care unit at a tertiary hospital: is emotional or existential suffering frequent?

ANTECEDENTES Y OBJETIVOS: Hoy en día la mayor difusión de los cuidados paliativos deriva en más pacientes atendidos y, por tanto, mayor complejidad en la sintomatología a tratar. En una situación de agonía puede haber síntomas refractarios que precisan sedación. El sufrimiento emocional, psicológico o existencial como causa de sedación no está muy claro entre los diferentes profesionales. Los objetivos de este estudio son: a) conocer la frecuencia de sedación en la agonía en una unidad de cuidados paliativos (UCP), la relación con el tipo de enfermedad del paciente y el motivo que la justificaba; b) revisar los fármacos y dosis empleadas, y el tiempo hasta el fallecimiento; c) valorar la necesidad de opioides en el momento del fallecimiento; d) analizar los pacientes que precisaron sedación por sufrimiento emocional o existencial. Material y método: Estudio retrospectivo de pacientes fallecidos en la Unidad de Cuidados Paliativos del Hospital Fundación Jiménez Díaz entre el 1 diciembre de 2015 y el 30 de septiembre de 2016. Se registraron: edad, tipo de enfermedad, necesidad de sedación en la agonía, síntoma principal que justificaba la sedación, fármacos empleados, dosis empleadas en el momento del fallecimiento, tiempo entre el inicio de la sedación y el fallecimiento, tipo de opioide y dosis en el momento del fallecimiento. Se registraron comentarios de la historia clínica de los pacientes con sufrimiento emocional o existencial refractarios que precisaron una sedación, y se revisó si habían precisado valoración por psicología o psiquiatría, y quién tomaba la decisión para iniciar la sedación. Se aplicó el test exacto de Fisher para las variables dicotómicas, y la t de Student para comparar las medias en grupos independientes. Resultados: Se incluyeron 299 pacientes (edad media 75,8 años, DS 11,2). Se registraron 234 pacientes con enfermedad oncológica (78 %), y 63 pacientes (21 %) con enfermedad no oncológica. Dos pacientes presentaban criterios de ambas. Precisaron sedación en la agonía 92 pacientes (31 %): 84 oncológicos y 8 no oncológicos. Hubo diferencias estadísticamente significativas (p < 0,001) entre la necesidad de sedación en los pacientes oncológicos y no oncológicos. Los principales motivos que justificaron una sedación fueron: delirium (34 pacientes, 37 %), sufrimiento espiritual (15 pacientes, 16 %) y multifactorial (14 pacientes, 15 %). Los principales fármacos empleados en la sedación fueron midazolam (93 %) y de forma combinada midazolam con un neuroléptico (67 %). La dosis en el momento del fallecimiento fueron 40,6 mg de midazolam y 90,5 mg levomepromazina. El tiempo entre el inicio de la sedación y el fallecimiento fue de 2,4 días (DS 1,7). El 95 % de los pacientes sedados recibían opioides en el momento del fallecimiento, principalmente cloruro mórfico parenteral, con una dosis media de 41,7 mg. La edad media de los pacientes que precisaron sedación por sufrimiento emocional o existencial fue 67,07 años (DS 10,20). El 87 % de estos pacientes recibieron valoración por psicología o psiquiatría, lo que facilitó que la mayoría de ellos (80 %) dieran su consentimiento para el inicio de la sedación. CONCLUSIONES: Casi un tercio de los pacientes que fallecieron en la UCP precisaron sedación. Los pacientes oncológicos precisaron sedación con mayor frecuencia que los pacientes no oncológicos, siendo esta diferencia estadísticamente significativa. El delirium y el sufrimiento emocional fueron las causas más frecuentes que justificaron una sedación en la agonía. Es frecuente el uso combinado de benzodiacepinas y neurolépticos en una sedación en la agonía. Las dosis medias de midazolam y levomepromazina en el momento del fallecimiento en pacientes sedados fueron similares a las registradas en otros estudios. El tiempo entre el inicio de la sedación y el fallecimiento fue de pocos días. El opioide más utilizado en el momento del fallecimiento de los pacientes sedados fue cloruro mórfico parenteral, aunque no todos los pacientes los precisaron. La sedación por sufrimiento emocional o existencial refractario es habitual en las UCP, aunque genera controversia entre los diferentes profesionales. Se recomienda hacer un abordaje multidisciplinar en cuidados paliativos para mejorar la atención a los pacientes con sufrimiento psicoexistencial

BACKGROUND AND OBJECTIVES: Nowadays palliative care treatments are well recognized, and many patients are referred with intractable symptoms. Patients in agony with refractory symptoms require sedation. The use of sedation for purely emotional or existential suffering is controversial. The objectives of this study are: a) to report the frequency of sedation in agony in a Palliative Care Unit (PCU), the relationship with the underlying disease, and the symptoms motivating sedation; b) to review the medications and dosage used to implement sedation, and to quantify the time from sedation to death; c) to describe the use and dosage of opioids at the end of life; d) to analyze the cases of patients undergoing sedation due to emotional or existential suffering. MATERIAL AND METHODS: A retrospective study of deceased patients at the PCU at Fundación Jiménez Díaz Hospital between December 1, 2015 and September 30, 2016 was performed. Registered variables included age, type of underlying disease, need of sedation during agony, main symptoms motivating sedation, medication used for sedation, dosage at the time of death, time between beginning of sedation and death, use of opioids and dosage of opioids at the time of death. The medical records of patients sedated due to emotional or existential suffering were reviewed, and the psychiatric and psychological assessment, as well as the decision-making process for sedation, were described. We used data query in Access XP, and the statistical analysis software package SPSS v15.0 in order to analyze results. Fisher's exact test and Student's t-test were used to prove statistical significance

Physician and Surrogate Agreement with Assisted Dying and Continuous Deep Sedation in Advanced Dementia in Switzerland.

BACKGROUND: Assisted dying and continuous deep sedation (CDS) are controversial practices. Little is known about the perceptions of physicians and surrogates about these practices for patients with advanced dementia. OBJECTIVES: To describe and compare physician and surrogate agreement with the use of assisted dying and CDS in advanced dementia. DESIGN, SETTING, SUBJECTS: Physicians (n = 64) and surrogates (n = 168) of persons with advanced dementia were recruited as part of a randomized controlled trial in Switzerland that tested decision support tools in this population. METHODS: At baseline, the participants were asked about their agreement with assisted dying and CDS in advanced dementia using the following response options: "completely agree," "somewhat agree," "somewhat disagree," "completely disagree," and "do not know." Multivariable logistic regressions compared the likelihood that surrogates versus physicians would completely or somewhat agree (vs. completely or somewhat disagree) with these practices. RESULTS: The physicians and surrogates, respectively, had a mean age (SD) of 50.6 years (9.9) and 57.4 years (14.6); 46.9% (n = 30/64) and 68.9% (n = 115/167) were women. A total of 20.3% (n = 13/64) of the physicians and 47.0% (n = 79/168) of the surrogates agreed with assisted dying in advanced dementia. Surrogates were significantly more likely to agree with this practice than physicians (adjusted odds ratio, 3.87; 95% CI: 1.94, 7.69). With regard to CDS, 51.6% (n = 33/64) of the physicians and 41.9% (n = 70/169) of the surrogates agreed with this practice, which did not differ significantly between the groups. CONCLUSIONS: The surrogates were more agreeable to considering assisted dying in the setting of advanced dementia than the physicians, and about half of the participants in both groups reported CDS to be an appropriate option for this population.

Analgesia, sedation, and delirium in pediatric surgical critical care.

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Visual Distraction During Sleep Induction with Propofol in Pediatric Patients - Can Cartoon Watching Influence the Sedative Dose?

BACKGROUND: In general anesthesia, cartoon watching and playing video games reduce anxiety in children. It is unknown whether watching a video in the intervention room has a similar effect, and therefore is able to reduce sedative doses in children undergoing small medical procedures. Aim of this prospective study was to determine the effect of watching a standardized cartoon immediately before and during sleep induction for deep sedation on consumption of propofol in children. PATIENTS AND METHODS: 50 children aged 2-14 years undergoing deep sedation were randomly assigned to 2 groups: (A) watching or (B) not watching a standardized videoclip during sleep induction with propofol. The achievement of predefined sedation depth was objectified by measuring Comfort Score (aim 10-14) and Bispectral Index (aim 50-60). RESULTS: The median sleep induction dose of propofol did not differ in both groups (A: 1.76 (0.62-4.37) mg/kg; B: 1.37 (0.66-5.26) mg/kgKG; p=0.65). Cartoon watching was associated with shorter sleep onset latency (A: 120 (60-480)s; B: 240 (40-600)s; p=0.043). Subgroup analysis reveals this especially for school children and girls. In both groups no complications occurred. CONCLUSION: Children watching a standard cartoon during sleep induction for deep sedation have a shorter sleep onset time but sedative dose is not reduced.

Endodontists' Intravenous Sedation-related Attitudes and Professional Behavior: A National Survey.

INTRODUCTION: Research shows that a high percentage of endodontic patients are interested in receiving intravenous (IV) sedation. The objectives of this study were to assess endodontists' IV sedation-related education, attitudes, and professional behavior and to explore whether providing versus not offering IV sedation procedures was associated with IV-related education and attitudes and whether background characteristics and education were related with IV sedation attitudes and behavior. METHODS: Data were collected with an anonymous Web-based survey from 616 members of the American Association of Endodontists (response rate = 29%). RESULTS: Only 10% of respondents agreed/strongly agreed that they had adequate training in IV sedation. However, 48% agreed/strongly agreed that there was a need for IV sedation in their practice. Although 69% did not offer IV sedation, 26% had another professional provide it, and 4% provided it themselves. These 3 groups of providers differed in the mean quality of their IV sedation-related education (scale from 1-5 with 5 = best education: 1.50 vs 1.62/2.37, P < .001) and the positivity of their attitudes toward IV sedation (2.90 vs 3.50/4.21, P < .001). Although the quality of IV sedation education was not correlated with the graduation year, the more recently respondents had graduated, the more positive they were toward providing education about IV sedation (r = .16, P < .001). CONCLUSIONS: Most endodontists did not evaluate their IV sedation-related graduate education positively. However, nearly half acknowledged the need for IV sedation in endodontics. The more recently they graduated, the more they agreed that IV sedation-related graduate education was needed but also that staff training and maintenance of equipment would be a problem.

Palliative sedation: clinical context and ethical questions.

Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal.

Spoken words are processed during dexmedetomidine-induced unresponsiveness.

BACKGROUND: Studying the effects of anaesthetic drugs on the processing of semantic stimuli could yield insights into how brain functions change in the transition from wakefulness to unresponsiveness. Here, we explored the N400 event-related potential during dexmedetomidine- and propofol-induced unresponsiveness. METHODS: Forty-seven healthy subjects were randomised to receive either dexmedetomidine (n=23) or propofol (n=24) in this open-label parallel-group study. Loss of responsiveness was achieved by stepwise increments of pseudo-steady-state plasma concentrations, and presumed loss of consciousness was induced using 1.5 times the concentration required for loss of responsiveness. Pre-recorded spoken sentences ending either with an expected (congruous) or an unexpected (incongruous) word were presented during unresponsiveness. The resulting electroencephalogram data were analysed for the presence of the N400 component, and for the N400 effect defined as the difference between the N400 components elicited by congruous and incongruous stimuli, in the time window 300-600 ms post-stimulus. Recognition of the presented stimuli was tested after recovery of responsiveness. RESULTS: The N400 effect was not observed during dexmedetomidine- or propofol-induced unresponsiveness. The N400 component, however, persisted during dexmedetomidine administration. The N400 component elicited by congruous stimuli during unresponsiveness in the dexmedetomidine group resembled the large component evoked by incongruous stimuli at the awake baseline. After recovery, no recognition of the stimuli heard during unresponsiveness occurred. CONCLUSIONS: Dexmedetomidine and propofol disrupt the discrimination of congruous and incongruous spoken sentences, and recognition memory at loss of responsiveness. However, the processing of words is partially preserved during dexmedetomidine-induced unresponsiveness. CLINICAL TRIAL REGISTRATION: NCT01889004.

Comfort in palliative sedation (Compas): a transdisciplinary mixed method study protocol for linking objective assessments to subjective experiences.

BACKGROUND: In case of untreatable suffering at the end of life, palliative sedation may be chosen to assure comfort by reducing the patient's level of consciousness. An important question here is whether such sedated patients are completely free of pain. Because these patients cannot communicate anymore, caregivers have to rely on observation to assess the patient's comfort. Recently however, more sophisticated techniques from the neurosciences have shown that sometimes consciousness and pain are undetectable with these traditional behavioral methods. The aim of this study is to better understand how unconscious palliative sedated patients experience the last days of their life and to find out if they are really free of pain. METHODS: In this study we will observe 40 patients starting with initiation of palliative sedation until death. Assessment of comfort based on behavioral observations will be related with the results from a NeuroSense monitor, an EEG-based monitor used for evaluation of the adequacy of anesthesia and sedation in the operating room and an ECG-based Analgesia Nociception Index (ANI) monitor, which informs about comfort or discomfort condition, based on the parasympathetic tone. An innovative and challenging aspect of this study is its qualitative approach; "objective" and "subjective" data will be linked to achieve a holistic understanding of the study topic. The following data will be collected: assessment of pain/comfort by the patients themselves (if possible) by scoring a Visual Analogue Scale (VAS); brain function monitoring; monitoring of parasympathetic tone; caregivers' assessment (pain, awareness, communication); relatives' perception of the quality of the dying process; assessment by 2 trained investigators using observational scales; video and audio registration. DISCUSSION: Measuring pain and awareness in non-communicative dying patients is both technically and ethically challenging. ANI and EEG have shown to be promising technologies to detect pain that otherwise cannot be detected with the "traditional" methods. Although these technologies have the potential to provide objective quantifiable indicators for distress and awareness in non-communicative patients, strikingly they have not yet been used to check whether the current assessments for non-communicative patients are reliable. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (Identifier: NCT03273244 ; registration date: 7.9.2017).

Euthanasia and palliative sedation in Belgium.

The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.

A Nationwide Survey About Palliative Sedation Involving Japanese Palliative Care Specialists: Intentions and Key Factors Used to Determine Sedation as Proportionally Appropriate.

CONTEXT: Although there has long been debate about physicians' intentions and what physicians consider to be proportionally appropriate when performing palliative sedation, few large studies have been performed. OBJECTIVES: To identify physicians' intentions when starting continuous deep sedation and to clarify what factors determine whether physicians regard sedation as proportionally appropriate in relation to expected survival, the patients' wishes, and refractoriness. METHODS: A nationwide questionnaire survey of Japanese palliative care specialists was performed from August to December 2016. We defined continuous deep sedation as the continuous use of sedatives to relieve intolerable and refractory symptoms with the loss of consciousness until death. RESULTS: Of the 695 palliative care specialists enrolled, 440 were analyzed (response rate, 69%). A total of 95% and 87% of the physicians reported that they explicitly intended to perform symptom palliation and decrease consciousness levels, respectively. Moreover, 38% answered that they explicitly intended to maintain unconsciousness until death, and 11% reported that they intended to shorten survival to some extent. The respondents considered that continuous deep sedation is more appropriate when the predicted survival is shorter, the patients' wishes are consistent and clear, and confidence in the refractoriness of symptoms is higher. CONCLUSIONS: Japanese palliative care specialists explicitly intend to control symptoms and reduce the level of consciousness when performing continuous deep sedation, but there are differences in their intentions with regard to maintaining unconsciousness until death. Predicted survival, patients' wishes, and confidence in refractoriness are associated with physicians' judgment that sedation is proportionally appropriate.

The 'French exception': the right to continuous deep sedation at the end of life.

In 2016, a law came into force in France granting terminally ill patients the right to continuous deep sedation (CDS) until death. This right was proposed as an alternative to euthanasia and presented as the 'French response' to problems at the end of life. The law draws a distinction between CDS and euthanasia and other forms of sympton control at the end of life. France is the first country in the world to legislate on CDS . This short report describes the particular context and underlying social values that led to this piece of legislation, and explores its meaning in the wider French context.

What influences intentions to request physician-assisted euthanasia or continuous deep sedation?

The increasing prevalence of euthanasia in Belgium has been linked to changing attitudes. Using National health survey data (N = 9651), we investigated Belgian adults' intention to ask a physician for euthanasia or continuous deep sedation in the hypothetical scenario of a terminal illness and examined its connection to sociodemographic and health characteristics. Respectively, 38.3 and 25.8% could envisage asking for euthanasia and continuous deep sedation. Those with very bad to fair subjective health and with depression more likely had an intention to ask for euthanasia, which suggests need for attention in the evaluation of requests from specific patient groups.

[End-of-life debate: Citizen's point of view about deep and continuous sedation]. / Débat sur la fin de vie en France : regard du citoyen sur la sédation profonde et continue.

INTRODUCTION: Sedation in palliative care meets a precise definition and corresponds to a medical practice. We assessed the comprehension of this practice by the French population. METHOD: In 2015, citizen expressed their views on the Claeys-Leonetti bill by means of a consultative forum made available on the Internet site of the National Assembly. The content of the messages filed, regarding the right to deep and continuous sedation until death was analyzed using the ALCESTE textual data analysis software, supplemented by a thematic analysis in order to identify the perception that Internet users had of this practice. RESULTS: Among the 1819 Internet users who participated in the forum, 67 expressed their views as Health professionals, 25 of whom were directly involved in palliative care, as well as 10 sick persons. Analysis with the ALCESTE software highlighted two classes of statements. The first dealing with deep and continuous sedation, reflecting the specificity of the discourse of the Internet users. The second one consisted of textual units in which the modal verbs were dominant and overrepresented, thus providing information on the participants' perceptions. The thematic analysis highlighted four themes: death, intent, treatment and fear. CONCLUSION: Deep and continuous sedation is perceived as a euthanasic practice or raises fear of such a drift. Provision of extended and accurate information to the population and health professionals is essential to ensure that this new model of sedation is integrated into the care of the terminally ill patients and their families.

Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views.

BACKGROUND: Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory. OBJECTIVES: The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress. METHODS: A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians. RESULTS: Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone. CONCLUSION: Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.

The impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being: a systematic review.

BACKGROUND: The practice of continuous deep sedation is a challenging clinical intervention with demanding clinical and ethical decision-making. Though current research indicates that healthcare professionals' involvement in such decisions is associated with emotional stress, little is known about sedation-related emotional burden. This study aims to systematically review the evidence on the impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being. METHODS: A systematic review of literature published between January 1990 and October 2016 was performed following a predefined protocol. MEDLINE, EMBASE, PubMed, Cochrane Library, CINAHL, Scopus, and PsycINFO were searched using search terms within "end-of-life care", "sedation", and "emotional well-being". Dissertations and reference lists were screened by hand. Two independent reviewers conducted study selection, data extraction and quality assessment. We abstracted measures of psychological outcomes, which were related to the practice of continuous deep sedation until death, including emotional well-being, stress and exhaustion. We used the GRADE approach to rate the quality of evidence. RESULTS: Three studies remained out of 528 publications identified. A total of 3'900 healthcare professionals (82% nurses, 18% physicians) from Japan (n = 3384) and the Netherlands (n = 16) were included. The prevalence of sedation-related burden in nurses varied from 11 to 26%, depending on outcome measure. Physicians showed medium levels of emotional exhaustion and low levels of depersonalization. Common clinical concerns contributing to professionals' burden were diagnosing refractory symptoms and sedation in the context of possibly life-shortening decisions. Non-clinical challenges included conflicting wishes between patients and families, disagreements within the care team, and insufficient professionals' skills and coping. Due to the limited results and heterogeneity in outcome measure, the GRADE ratings for the quality of evidence were low. CONCLUSIONS: Current evidence does not suggest that practicing continuous deep sedation is generally associated with lower emotional well-being of healthcare professionals. Higher emotional burden seems more likely when professionals struggled with clinical and ethical justifications for continuous deep sedation. This appeared to be in part a function of clinical experience. Further research is needed to strengthen this evidence, as it is likely that additional studies will change the current evidence base.

Non-anesthesiologist-administered Propofol is not Related to an Increase in Transcutaneous CO2 Pressure During Flexible Bronchoscopy Compared to Guideline-based Sedation: A Randomized Controlled Trial.

INTRODUCTION: Evidence for the use of non-anesthesiologist-administered propofol for sedation during flexible bronchoscopy is scarce. The main objective of this study was to determine whether non-anesthesiologist-administered propofol balanced sedation was related to higher transcutaneous CO2 pressure compared with current guideline-based sedation (combination midazolam and opioid). Secondary outcomes were post-procedural recuperation time, patient satisfaction and frequency of adverse events. METHODS: In this randomized controlled trial we included data from outpatients aged 18 years or older with an indication for flexible bronchoscopy in a university hospital in northern Mexico. RESULTS: Ninety-one patients were included: 42 in the midazolam group and 49 in the propofol group. During 60min of transcutaneous capnometry monitoring, mean transcutaneous CO2 pressure values did not differ significantly between groups (43.6 [7.5] vs. 45.6 [9.6]mmHg, P=.281). Propofol was related with a high Aldrete score at 5, 10, and 15min after flexible bronchoscopy (9 [IQR 6-10] vs. 10 [9,10], P=.006; 9 [8-10] vs. 10 [IQR 10-10], P<.001 and 10 [IQR 9-10] vs. 10 [10], respectively) and with high patient satisfaction on a visual analogue scale of 1 (not satisfied) to 10 (very satisfied) (8.41 [1.25] vs. 8.97 [0.98], P=.03). Frequency of adverse events was similar among groups (30.9% vs. 22.4%, P=.47). CONCLUSION: Compared with guideline-recommended sedation, non-anesthesiologist-administered propofol balanced sedation is not associated with higher transcutaneous CO2 pressure or with more frequent adverse effects. Propofol use is associated with faster sedation recovery and with high patient satisfaction. CLINICAL TRIAL REGISTRATION: NCT02820051.