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Continuous sedation until death in nursing homes in flanders, belgium: Palliative sedation or slow euthanasia?
S40
9th Congress of the EUGMS / European Geriatric Medicine 4 (2013) S20–S80
P067
Continuous sedation until death in nursing homes in flanders, belgium: Palliative sedation or slow euthanasia? S. Rys , J. Bilsen Department of Public Health, Vrije Universiteit, Brussel, Belgium Introduction.– Continuous Sedation until Death (CSD), the removal of consciousness of an incurably ill patient until death, has become a controversial topic of medical-ethical debate. Some describe CSD as “palliative sedation” (PS); a treatment with the aim of relieving suffering, not shortening the patient’s life. Others claim that CSD is frequently misused to perform “slow euthanasia” (SE); the administration of sedation with the intention to hasten death gradually. Given the increasing rate of CSD in nursing homes in Flanders (Belgium), and the significant low rate of legal euthanasia, this study wants to examine to what extent CSD amounts to either PS or SE, as well as the characteristics associated with these different practices. Methods.– A questionnaire was sent to all coordinating and advisory physicians of nursing homes in Flanders (n = 660). The questionnaire contained questions on the patient these physicians had most recently treated with CSD. Results.– The response rate was 57.3%. A case of CSD was reported by 159 physicians (42.1%). According to the reported intentions involved, 62.2% of these cases can be considered as PS (no lifeshortening intentions reported), while 37.8% of the cases can be characterized as SE (life-shortening intentions reported). Factors such as palliative care training, education on CSD, or knowledge of sedation guidelines did not affect the outcome distribution (PS or SE). In SE, the patient has a longer life expectancy, is more competent, is clearly longing for death, and requests for euthanasia more frequently. Physicians preferred SE over legal euthanasia: to avoid the legal procedure, because they or the patient preferred sedation, or because legal euthanasia was not allowed by the nursing home’s policy. Key conclusions.– CSD is frequently used as a substitute for legal euthanasia in nursing homes in Flanders. This raises a serious public health issue; as such cases are not subject to any societal control – unlike legal euthanasia. Our findings do not support the role of education on CSD (or palliative care in general) in preventing the abuse of CSD.
resuscitation would leave him in a vegetative state and prolong his suffering. His death was viewed by his family as a failure to keep him alive. Family discord ensued as he expressed his comfort care wishes. Later palliative care team interventions helped him make decisions of comfort care, which was most appropriate. Conclusion.– Approaching goals of care discussion should be started early in the disease process when a poor prognosis is realized. End of life care should be approached and discussed as living comfortably until the end. http://dx.doi.org/10.1016/j.eurger.2013.07.132 P069
Recognising the role of palliative medicine in elderly patients presenting as acute admissions S.Q. Warraich ∗ , J. Fletcher ∗ , R. Banerjee OUH Oxford University Hospitals, Oxford, UK ∗ Corresponding authors.
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Introduction.– Palliative medicine has historically played a key role in the care of young patients with malignant disease. Palliative care (PC) input is important in the dignified and holistic end-of-life care of patients with chronic conditions. The aim of this audit was to determine how many adult and elderly inpatients were referred to PC during their last hospital admission. Methods.– Adult deaths at the John Radcliffe Hospital were independently reviewed over 27 consecutive days. The total number of referrals made to PC and the age-adjusted Charlson index for each patient were calculated. Results.– Eighty-seven deaths were recorded in total, of whom 73 adults had registered causes of death, and were analysed in the final cohort. Only ten patients (14%) died with PC input, despite many more having predictably poor clinical outcomes. Forty patients (54%) were admitted with known chronic disease, with 21 of these aged > 80, yet only four were referred to PC. Average age of death was 80 (range 49–101). However, age did not impact on referrals to PC. Using the age-adjusted Charlson co-morbidity index, 14 patients of our cohort scored ≥ 8, signifying multiple comorbidities and a poor prognosis, yet only two were referred to PC. Key conclusions.– Most end-of-life care patients were not referred to PC, despite predictable complications arising from chronic disease. This may reflect a reduced awareness of the conditions appropriate for referral. Our findings suggest that the majority of in-hospital deaths are elderly patients with multiple co-morbidities who need improved access to palliative medicine.
Is death a failure?
http://dx.doi.org/10.1016/j.eurger.2013.07.133
http://dx.doi.org/10.1016/j.eurger.2013.07.131
S. Datta , P.Y. Takahashi , A. Yu-Ballard Mayo Clinic, Rochester, MN, United States Introduction.– Death and dying are emotionally burdening issues both for patients and physicians. Quality care at end-of-life and improvising effective conversations about the end-of-life is an imperative part of improving that care. We present a case of a gentleman who struggled to make end of life decisions leading to more emotional and physical distress. Case.– 70-year-old community dwelling retired professional had recurrent metastatic colorectal adenocarcinoma despite treatment. He had ureteral obstruction from pelvic mass needing nephrostomy tube and transverse colostomy due to obstructing sigmoid and rectal tumor. He was previously independent, but now was completely ADL dependent due to debility. He had denied all home health services as it was against his principles. He started palliative radiation for large pelvic metastatic mass, and subsequently developed urosepsis requiring ICU care. Patient clearly understood the outcomes and prognosis of his disease, but his wife and children had unrealistic expectations of curing the disease with radiation treatments. His decision was guided by his family, realizing that
P070
Prolonged-release oxycodone/naloxone is effective in treating pain and constipation in elderly patients with neuropathic pain A. Gatti a,b , M. Lazzari a,b , M. Casali a,b , P. Gafforio a,b , E. Palombo a,b , B. Bosse a,b , A.F. Sabato a,b a Emergency Care, Critical Care Medicine, Pain Medicine and Anesthesiology Department, Policlinico Tor Vergata University of Rome Tor Vergata, Rome, Italy b Mundipharma Research GmbH & Co.KG, Limburg, Germany Introduction.– Opioids are the elective treatment for severe pain. The fixed-dose combination of oxycodone and naloxone (OXNPR) has been developed to address the problem of opioid-induced bowel dysfunction. This retrospective, observational, single-centre study investigated OXNPR in a real-life setting, including in elderly patients with neuropathic pain (NP).
9th Congress of the EUGMS / European Geriatric Medicine 4 (2013) S20–S80
P067
Continuous sedation until death in nursing homes in flanders, belgium: Palliative sedation or slow euthanasia? S. Rys , J. Bilsen Department of Public Health, Vrije Universiteit, Brussel, Belgium Introduction.– Continuous Sedation until Death (CSD), the removal of consciousness of an incurably ill patient until death, has become a controversial topic of medical-ethical debate. Some describe CSD as “palliative sedation” (PS); a treatment with the aim of relieving suffering, not shortening the patient’s life. Others claim that CSD is frequently misused to perform “slow euthanasia” (SE); the administration of sedation with the intention to hasten death gradually. Given the increasing rate of CSD in nursing homes in Flanders (Belgium), and the significant low rate of legal euthanasia, this study wants to examine to what extent CSD amounts to either PS or SE, as well as the characteristics associated with these different practices. Methods.– A questionnaire was sent to all coordinating and advisory physicians of nursing homes in Flanders (n = 660). The questionnaire contained questions on the patient these physicians had most recently treated with CSD. Results.– The response rate was 57.3%. A case of CSD was reported by 159 physicians (42.1%). According to the reported intentions involved, 62.2% of these cases can be considered as PS (no lifeshortening intentions reported), while 37.8% of the cases can be characterized as SE (life-shortening intentions reported). Factors such as palliative care training, education on CSD, or knowledge of sedation guidelines did not affect the outcome distribution (PS or SE). In SE, the patient has a longer life expectancy, is more competent, is clearly longing for death, and requests for euthanasia more frequently. Physicians preferred SE over legal euthanasia: to avoid the legal procedure, because they or the patient preferred sedation, or because legal euthanasia was not allowed by the nursing home’s policy. Key conclusions.– CSD is frequently used as a substitute for legal euthanasia in nursing homes in Flanders. This raises a serious public health issue; as such cases are not subject to any societal control – unlike legal euthanasia. Our findings do not support the role of education on CSD (or palliative care in general) in preventing the abuse of CSD.
resuscitation would leave him in a vegetative state and prolong his suffering. His death was viewed by his family as a failure to keep him alive. Family discord ensued as he expressed his comfort care wishes. Later palliative care team interventions helped him make decisions of comfort care, which was most appropriate. Conclusion.– Approaching goals of care discussion should be started early in the disease process when a poor prognosis is realized. End of life care should be approached and discussed as living comfortably until the end. http://dx.doi.org/10.1016/j.eurger.2013.07.132 P069
Recognising the role of palliative medicine in elderly patients presenting as acute admissions S.Q. Warraich ∗ , J. Fletcher ∗ , R. Banerjee OUH Oxford University Hospitals, Oxford, UK ∗ Corresponding authors.
P068
Introduction.– Palliative medicine has historically played a key role in the care of young patients with malignant disease. Palliative care (PC) input is important in the dignified and holistic end-of-life care of patients with chronic conditions. The aim of this audit was to determine how many adult and elderly inpatients were referred to PC during their last hospital admission. Methods.– Adult deaths at the John Radcliffe Hospital were independently reviewed over 27 consecutive days. The total number of referrals made to PC and the age-adjusted Charlson index for each patient were calculated. Results.– Eighty-seven deaths were recorded in total, of whom 73 adults had registered causes of death, and were analysed in the final cohort. Only ten patients (14%) died with PC input, despite many more having predictably poor clinical outcomes. Forty patients (54%) were admitted with known chronic disease, with 21 of these aged > 80, yet only four were referred to PC. Average age of death was 80 (range 49–101). However, age did not impact on referrals to PC. Using the age-adjusted Charlson co-morbidity index, 14 patients of our cohort scored ≥ 8, signifying multiple comorbidities and a poor prognosis, yet only two were referred to PC. Key conclusions.– Most end-of-life care patients were not referred to PC, despite predictable complications arising from chronic disease. This may reflect a reduced awareness of the conditions appropriate for referral. Our findings suggest that the majority of in-hospital deaths are elderly patients with multiple co-morbidities who need improved access to palliative medicine.
Is death a failure?
http://dx.doi.org/10.1016/j.eurger.2013.07.133
http://dx.doi.org/10.1016/j.eurger.2013.07.131
S. Datta , P.Y. Takahashi , A. Yu-Ballard Mayo Clinic, Rochester, MN, United States Introduction.– Death and dying are emotionally burdening issues both for patients and physicians. Quality care at end-of-life and improvising effective conversations about the end-of-life is an imperative part of improving that care. We present a case of a gentleman who struggled to make end of life decisions leading to more emotional and physical distress. Case.– 70-year-old community dwelling retired professional had recurrent metastatic colorectal adenocarcinoma despite treatment. He had ureteral obstruction from pelvic mass needing nephrostomy tube and transverse colostomy due to obstructing sigmoid and rectal tumor. He was previously independent, but now was completely ADL dependent due to debility. He had denied all home health services as it was against his principles. He started palliative radiation for large pelvic metastatic mass, and subsequently developed urosepsis requiring ICU care. Patient clearly understood the outcomes and prognosis of his disease, but his wife and children had unrealistic expectations of curing the disease with radiation treatments. His decision was guided by his family, realizing that
P070
Prolonged-release oxycodone/naloxone is effective in treating pain and constipation in elderly patients with neuropathic pain A. Gatti a,b , M. Lazzari a,b , M. Casali a,b , P. Gafforio a,b , E. Palombo a,b , B. Bosse a,b , A.F. Sabato a,b a Emergency Care, Critical Care Medicine, Pain Medicine and Anesthesiology Department, Policlinico Tor Vergata University of Rome Tor Vergata, Rome, Italy b Mundipharma Research GmbH & Co.KG, Limburg, Germany Introduction.– Opioids are the elective treatment for severe pain. The fixed-dose combination of oxycodone and naloxone (OXNPR) has been developed to address the problem of opioid-induced bowel dysfunction. This retrospective, observational, single-centre study investigated OXNPR in a real-life setting, including in elderly patients with neuropathic pain (NP).